SAFEStatementofWork_10.16.15.docx

PROCUREMENT SENSITIVE: USAID/PEPFAR SAFE -- Supporting and AIDS-Free Era

Statement of Work

USAID/PEPFAR SAFE: Supporting an AIDS-Free Era

TABLE OF CONTENTS

Acronym List

1.0 Introduction

The purpose of Supporting an AIDS-Free Era (SAFE) is to reduce HIV mortality, morbidity and transmission, while improving nutrition outcomes and family planning integration in the six USAID-supported provinces.

2.0 Background

Country Context Zambia’s population is estimated at 15 million people. At 741,000 square kilometers (286,000 square miles) Zambia is slightly larger than the U.S. state of Texas and is geopolitically divided into ten provinces and over 100 districts. Approximately 60 percent of the population lives in sparsely populated rural areas.

Zambia has made significant progress in managing its generalized HIV epidemic over the past decade, with UNAIDS estimating at least a 50 percent reduction in new infections between 2000 and 2012, and a halving in the number of HIV-related deaths according to the 2013 -2014 Zambia Demographic and Health Survey (ZDHS). While prevalence has decreased one percentage point since 2007, Zambia still suffers from one of the world’s most devastating HIV/AIDS epidemics, with a current prevalence of 13.3 percent.

Prevalence among women in Zambia, compared to their counterparts in the region, continues to be higher than among men. UNAIDS estimates the differential as 16.1 vs. 12.3 percent, while the ZDHS measured 15.1 vs. 11.3 percent. The difference in HIV sero-prevalence is particularly striking among the age group of 20 - 24 years, where young women are six times more likely (12 percent versus 2 percent) to be HIV infected than young men (Population Council, 2013); the measurement from the 2013/14 ZDHS is 11.2 for young women vs 7.3 for young men.

HIV prevalence is twice as high in urban areas (18.2 percent) compared to rural areas (9.1 percent), and the epidemic is geographically diverse, with provincial prevalence ranging from 6.4 percent to 18.2 percent. The Muchinga and Northwestern provinces, both predominantly rural with low population densities, have the lowest prevalence, at 6.4 percent and 7.2 percent respectively. In six of Zambia’s ten provinces, much of prevalence is concentrated in “hotspots” in the provincial capitals and some districts. In contrast, Lusaka and Copperbelt Provinces have densely populated urban areas with a prevalence of 16 percent or higher.

Food and nutrition support is a critical component of HIV/AIDS treatment and care. HIV and malnutrition interact in a vicious cycle; leading to severe morbidity and mortality. For many people living with HIV (PLHIV), the infection causes or aggravates malnutrition through reduced food intake, increased energy needs, impaired nutrient absorption and nutrient losses associated with frequent and persistent diarrhea. Malnutrition can hasten the progression of HIV to AIDS, further weakening the immune system and increasing susceptibility to and complicating treatment of opportunistic infections (OI) as well as reducing the effectiveness of antiretroviral therapy (ART). Food insecurity and malnutrition remain highly prevalent in most sub-Saharan African countries, including Zambia. Thus, Nutrition Assessment Counselling and Support (NACS) is a critical component of management of patients with HIV and AIDS. According to the ZDHS, nationally, 40 percent of children under age 5 are stunted, and 17 percent are severely stunted. Analysis by age groups shows that stunting is highest (54 percent) in children age 18-23 months and lowest (14 percent) in children less than 6 months of age. Severe stunting shows a similar pattern, with the highest proportion among children age 18-23 months (25 percent). Stunting is higher in male than in female children (42 percent versus 38 percent). Stunting decreases as the length of the preceding birth interval increases; it is highest among children born less than 24 months following a previous birth (46 percent) and lowest among children born 48 or more months after a preceding birth (34 percent). More than half of children whose size at birth was very small (62 percent) or small (52 percent) are stunted. Mothers’ nutritional status, as measured by their body mass index, also has an impact on the level of stunting in their children. Stunting is most likely (50 percent) among children whose mothers are thin (BMI of less than 18.5) and least likely (32 percent) among children whose mothers are overweight or obese (BMI of 25 or above).

While modern contraceptive prevalence is relatively high compared to other countries in the region at 44.8%, family planning services are poorly integrated into HIV services and only 4% of women report using male condoms, one of the most cost-effective HIV prevention interventions. Further, 11.3% of all couples in Zambia are HIV discordant, with rates of discordance higher among couples with significant age differences (13% - 15%, depending on the age category), and urban couples (15.8%). Primary health care facilities make up the largest source of family planning methods, with 69 percent of users obtaining their method from government health centers and posts.

The HIV response in Zambia is coordinated by the National HIV/TB/STI Council (NAC) and the Ministry of Health (MOH) with the MOH taking the primary lead on HIV/AIDS and nutrition activities. Stakeholders implementing HIV activities include the Zambian government, international bilateral and multilateral cooperating partners, local and international non-governmental organizations, civil society organizations and Zambian communities. The country’s long-term vision calls for a “nation free from the threat of HIV and AIDS by 2030.”

The main goals of the HIV treatment program in Zambia are to increase HIV treatment coverage for all PLHIV to 80 percent; reduce AIDS-related mortality by 50 percent and enhance HIV prevention. Only 50 percent of persons living with HIV/AIDS (PLWHA), however, are actually receiving HIV treatment. These data underscore the continued need for improved access to and utilization of comprehensive HIV/AIDS services, including testing and counseling, prevention of mother-to-child transmission of HIV (PMTCT), voluntary medical male circumcision (VMMC), ART, and clinical care and support.

National Policy Context

Zambia’s Revised Sixth National Development Plan (SNDP) envisions equitable access to quality healthcare for all its citizens by 2030 and recognizes that a healthy population is critical to improved production and productivity. The SNDP specifically identifies the goal of a well- nourished and healthy population by 2030, and highlights the importance of maternal and child nutrition programs in achieving this goal, Additionally, the National Health Strategic Plan (NHSP) promotes access, as close to the community as possible, to high quality and cost-effective health services. The key principles of the NHSP include availability of primary health care services, equity of access, affordability, cost-effectiveness, accountability, partnership, decentralization, leadership and a clean, caring and competent health care environment. The NHSP outlines health system strengthening priorities based on the six World Health Organization (WHO) building blocks. The plan also identifies maternal, neonatal and child health, HIV/AIDS and sexually transmitted infections, tuberculosis and malaria as public health priorities. The Government of the Republic of Zambia (GRZ) has committed to providing essential health care to all Zambians through the implementation of a Basic Health Care Package that includes services based on an epidemiological analysis of the diseases and conditions that cause the highest burden of disease and death.

Family planning is part of the government’s integrated reproductive health services and is further outlined in the Eight-Year Integrated Family Planning Scale-Up Plan (2013-2020). At a national level, the goal is to increase contraceptive prevalence rate of modern methods from 33 to 58 percent by 2020, in line with the commitments made by the Zambian government at the London Summit in July 2012.

Another national plan guiding USAID’s work in Zambia is the Revised National HIV/AIDS Strategic Framework (R-NASF) 2014-2016. The framework is a roadmap to achieve Zambia’s vision of “a nation free from the threat of HIV and AIDS” and to reach the goal of reducing new infections by 50 percent, while scaling up treatment, care and support. It lays out the objectives of the national response:

1. Reduce new HIV infections by 50%;

2. Reduce AIDS related mortality by 50%;

3. Reduce HIV related stigma and discrimination by 50%; and

4. Increase domestic financing of the HIV response to 20%.

Zambia committed to reduce mother-to-child transmission of HIV/AIDS by 95 percent by 2015. The R-NASF also places emphasis on the prevention of infections in the populations most at risk, such as sex workers and mobile populations. USAID continues to have a major role in this response through PEPFAR-financed activities.

The draft Zambian HIV/AIDS commodity security strategy (2009-2010) discusses the availability of nutrient supplements for nutrition care and treatment programming. The document targets the availability and standardization of information on the use of supplemental and therapeutic nutrient products for ART, PMTCT, and Tuberculosis (TB) clients. It suggests that strategies should include the identification and treatment of malnutrition, improvement of nutrition-related counseling and support, supply chain management for nutrient commodities, and building capacity in the health system by the deployment and retention of trained nutritionists.

PEPFAR/USAID’s HIV/AIDS Response in Zambia

In early 2003, U.S. President George W. Bush announced PEPFAR, a five-year, $15-billion program aimed at fighting HIV/AIDS around the world. The program prioritized assistance for 15 of the world’s most severely HIV/AIDS-affected nations, including Zambia. Now in its third phase, PEPFAR has evolved into a program focused on helping countries build a long-term, sustainable response to fight HIV/AIDS. In its third authorization, PEPFAR expands existing commitments around service delivery and strengthens emphasis on sustainability and country ownership.

At the onset of the PEPFAR program in Zambia in 2004, because the HIV/AIDS problem was a generalized epidemic, urgent concerted steps were required to reverse the epidemic’s tide. This led to splitting the country into two service delivery regions, with the Centers for Disease Control and Prevention (CDC) working in the four southern provinces and USAID in the five northern provinces. A new province was subsequently created in 2012, bringing the total number of USAID supported provinces to six. The six northern provinces contain both provinces with a high disease burden and provinces with low HIV prevalence, although the latter contain well-defined high-prevalence HIV areas (“hotspots”). With the exception of Copperbelt Province, which is urbanized, the other provinces are predominantly rural, with poor road networks and health infrastructure. The geographic scope of the six “USAID” provinces comprises 57 districts and approximately 1,017 health facilities.

With PEPFAR support, USAID scaled up its activities and initiated a number of interventions, which have significantly contributed to rolling back the HIV/AIDS epidemic in Zambia. Support has strengthened a national and community-based response; improved service delivery systems and institutions; and implemented a broad portfolio of proven interventions and innovative activities. Within the health and integrated approach to service delivery, USAID has supported a number of partners to scale up the HIV/AIDS response, including: supporting facility-based service delivery; expanding and improving service delivery through bilateral programs; and leveraging the private sector. Additionally, concerted steps strengthened health infrastructure at all levels, with a focus on decentralization and support to local government and local organizations.

In partnership with the GRZ, these activities had a number of positive results:

· Enrolled over 600,000 HIV-infected patients in ART at more than 530 clinics nationwide, representing a 50 percent treatment coverage of PLHIV;

· Revised the Zambia Consolidated Guidelines for Treatment and Prevention of HIV Infections to expand treatment eligibility to include all HIV-infected children and adolescents under age 15, infected adolescents aged 15 and older, and adults with a CD4 count under 500 cells/mm3;

· Implemented Option B+ for HIV+ pregnant women; and

· Scaled-up of TB/HIV activities in Zambia: Approximately 90 percent of TB patients know their HIV status, 93 percent of HIV-positive TB patients are on cotrimoxazole, and ART coverage for TB/HIV patients has risen.

PEPFAR and USAID/Zambia Projects in Zambia

On August 6, 2014, the Accelerating Children’s HIV/AIDS Treatment Initiative (ACT) was announced, in conjunction with the U.S.-Africa Leaders’ Summit, PEPFAR and the Children’s Investment Fund Foundation (CIFF). The objective of ACT is to double the total number of children receiving life-saving ART across at least 10 sub-Saharan African countries over 2014-2016. Zambia has been identified as an ACT eligible country, and USAID-supported activities will align to support the ACT goal.

The USAID Health Care Improvement (HCI) and follow-on Applying Science to Strengthen and Improve Systems (ASSIST) projects, with FANTA-3 and Thrive, have implemented NACS in numerous countries with significant results identifying and improving the nutritional status of PLHIV and other key populations. The project seeks to improve prevention and management of malnutrition in PLHIV by: integrating NACS into facility-based ART, PMTCT and MNCH services; strengthening community-facility linkages; and strengthening the capacities of district health managers and care providers to apply improvement skills. To date, these projects have focused primarily on case identification and categorization, as well as retention of malnourished clients. There is now a need to focus more on the effectiveness of treatment on nutritional status of PLHIV and the contribution of NACS services to larger goals of HIV/AIDS support.

USAID Systems for Better Health is a 5-year project working with the GRZ to develop and implement national strategies and plans that address key system challenges faced by the health sector. The project will provide technical assistance to the MOH to build the capacity of health managers and professionals at the national, provincial, district, and facility levels to plan, implement, monitor, and evaluate health, including HIV, programs. Systems for Better Health will be implemented in a maximum of 28 districts spread across seven provinces, including Copperbelt, Central, Eastern, Lusaka, Luapula and Southern provinces.

Annex B contains a comprehensive list of ongoing and completed projects in Zambia relevant to SAFE.

3.0 Project Purpose and Objectives

The purpose of SAFE is to reduce HIV mortality, morbidity and transmission, while improving nutrition outcomes and family planning integration in the six USAID-supported provinces. The SAFE contractor will primarily utilize a technical assistance approach to strengthen services at the district and facility level, and a direct service delivery model at the community level. SAFE activities are informed by analyses including gender, policy, and cost-effectiveness analyses, and consultation with the Zambian government, U.S. Government agencies, civil society, private sector, research institutions, donors and other stakeholders.

In general, after five years of implementation, SAFE will have achieved its intended purpose by having:

· Reached 80 percent of eligible HIV-positive adults and children with antiretroviral treatment across SAFE districts;

· Reduced HIV-related deaths by 50 percent;

· Improved the quality of life for HIV-infected people by maintaining viral suppression for 90 percent of beneficiaries on HIV treatment;

· Lowered the incidence of new HIV infections by 50 percent;

· Reached 90 percent of the HIV positive adults and children with NACS; and

· Reduced wasting by 50 percent among HIV positive adults and children.

As a result of this project, a sustainable HIV/AIDS response, with a focus on epidemic control, will be achieved through the following objectives:

Objective 1: Increase access to and utilization of quality HIV/AIDS services.

Expected outcomes are:

· Improved range of comprehensive HIV/AIDS services;

· Improved quality of comprehensive HIV/AIDS services;

· Increased coverage of comprehensive HIV/AIDS services;

· Community involvement and participation in providing HIV services; and

Objective 2: Improve the capacity of MOH and MCD at the provincial and district levels to provide comprehensive, high-impact HIV/AIDS services.

Expected outcomes are:

· Strengthened ability to provide decentralized services;

· Increased professional and institutional capacity for management of HIV/AIDS services; and

· Successful transition of select SAFE program components to the GRZ.

Objective 3: Integrate family planning services into all HIV/AIDS service programs in the six supported provinces.

Expected outcomes are:

· Increased access to family planning services at facilities that provide HIV/AIDS services.

Objective 4: Improve the health and well-being of PLHIV through improving NACS services.

Expected outcomes are:

· NACS services implemented in SAFE facilities and communities; and

· Improved linkages between clinical and community economic strengthening, livelihoods and food security services.

Objective 5: Strengthen the GRZ’s capacity to manage Government-to-Government (G2G) funds

SAFE is part of a larger effort to achieve sustainable epidemic control, and the SAFE contractor must work with other stakeholders to achieve this objective. A key component of this effort is USAID’s G2G initiative with the GRZ. USAID anticipates providing funding directly to the MOH to increase the resources available to the GRZ in its efforts to control the HIV epidemic. The purpose of G2G funding is to utilize host country government systems to address the HIV epidemic while strengthening local systems and increasing country ownership. Under this arrangement, the GRZ will be the primary provider of direct services, while the SAFE contractor will implement specific activities defined in this SOW to increase access to and utilization of HIV prevention and treatment services and provide technical assistance to strengthen the services provided by the GRZ. Additionally, the SAFE contractor will build the capacity of the GRZ to manage USAID resources. USAID anticipates G2G funding levels to increase over the life of the SAFE contract, with select activities originally implemented by the SAFE contractor eventually becoming the responsibility of the GRZ as the contract progresses. As defined in Task 2.2, the SAFE contractor will also work with the GRZ to ensure the smooth transition of specific activities from SAFE to the GRZ.

Expected outcomes are:

· Improved budgetary systems of the Ministry of Finance (MOF) and MOH; and

· Improved procurement operations, including but not limited to, procurement planning, contract administration, and supplier management, of the MOF and MOH.

4.0 Scope

4.1 Geographic Scope and Focus

The SAFE contractor must work in the following provinces: Central, Copperbelt, Luapula, Muchinga, Northern, and North-Western. The level of effort for each district within these provinces will be determined by their priority classification, a ranking determined by USAID/Zambia, in coordination with OGAC and CDC, through epidemiologic data and potential to curb the HIV epidemic. Priority classification definitions (scale-up, sustained, and centrally supported) and district assignments are provided in Table 1 below.

Facilities within each district will also be assigned a priority classification (scale up, sustained, centrally supported). Throughout the life of the activity, USAID may direct the SAFE contractor to adjust and shift targeted districts and facilities within the six SAFE provinces based on changing epidemiological factors.

4.2 Technical Focus

The SAFE contractor must provide assistance to establish and roll out service delivery systems where they may be lacking, strengthen existing service delivery platforms, and strengthen the ability of the GRZ to manage USAID G2G funding. Support to direct service delivery systems must focus on the following HIV/AIDS program areas: PMTCT; HTC; ART; VMMC; Nutrition, basic care and support; TB/HIV; laboratory support; post-exposure prophylaxis for both pediatrics and adults; FP/ MNCH integration at ART facilities; strategic information for HIV-related services; and facility management system support, including for laboratory services, patient flow enhancement, pharmacy, records, reports and waste management.

Districts and facilities that are classified as scale-up will require a comprehensive package of core services that includes infrastructure upgrades, improved district and facility management, improved patient management, active case identification, and other interventions that maximize the capacity of facilities and increase the number of patients seeking services. Sustained districts and facilities include much of the same activities as scale-up districts, but do not include an active case finding approach. Centrally supported districts and facilities will have no facility level activity, but will be supported by activities at the provincial level that strengthen planning and implementation of the overall, province-wide HIV response.

Table 1. District Priority Classification and Associated Core Service Packages

Scale-Up

Chisamba (Central) Kabwe (Central) Mumbwa Central Serenje (Central) Chililabombwe (Copperbelt) Chibombo (Central) KapiriMposhi (Central) Mkushi (Central) Chingol (Copperbelt) Kalulushi (Copperbelt) Kitwe (Copperbelt) Mufulira (Copperbelt) Ndola (Copperbelt) Solwezi (North-Western) Kalumbila (North-Western) Mushindamo (North-Western) Laboratory, pharmacy and infrastructure upgrades;

· Diagnostic (equipment and reagents)

· Laboratory monitoring platforms (viral load, CD4，etc.)

· Pharmacy logistics/upgrades Clinical management

· Increasing access to HIV treatment to reach 80% of PLHIV

· Increasing utilization of HIV services

· Strengthening monitoring of patients (clinical and surrogate)

· Adherence support

· Retention on HIV treatment

· Pre-ART services (care and support services)

· Alternative service delivery models (private sector and community systems)

Strengthening data management systems including electronic health register

Active case identification

· Demand generation

· Community-based mobilization

· Intensified provider initiated testing and counseling (PITC)

Sustained

Luanshya (Copperbelt) Mpongwe (Copperbelt) Kawambwa (Luapula) Mansa (Luapula) Nchelenge (Luapula) Samfya (Luapula) Chinsali (Muchinga) Isoka (Muchinga) Mpika (Muchinga) Nakonde (Muchinga)

Luwingu (Northern) Mbala (Northern) Mporokoso (Northern) Mpulungu (Northern) Laboratory, pharmacy and infrastructure upgrades;

· Diagnostic (equipment and reagents)

· Laboratory monitoring platforms (viral load, CD4，etc.)

· Pharmacy logistics/upgrades Clinical management

· Increasing access to HIV treatment to reach 80% of PLHIV

· Increasing utilization of HIV services

· Strengthening monitoring of patients (clinical and surrogate)

· Adherence support

· Retention on HIV treatment

· Pre-ART services (care and support services)

· Alternative service delivery models (private sector and community systems)

Strengthening data management systems including electronic health register

Passive case identification

· No demand creation activities

· Provision of PITC for clinical symptomology

Ngabwe (Central) Lufwanyama (Copperbelt)

Chembe (Luapula) Lunga (Luapula) Milenge (Luapula) Mwansabombwe (Luapula) Mwense (Luapula) Chama (Muchinga) Mafinga (Muchinga) Shiwa'Ngandu (Muchinga) Chilubi (Northern) Mungwi (Northern) Nsama (Northern) Chavuma (North-Western) Ikelenge (North-Western) Kabompo (North-Western) Kasempa (North-Western) Manyinga (North-Western) Mufumbwe (North-Western) Mwinilunga (North-Western) Zambezi (North-Western)

· Technical assistance to PMO

As of FY 2014, there were 360,348 PLHIV in the 16 scale-up districts (saturation and aggressive). Of these, 207,365 are currently on ART, leaving an unmet need of 152,983 within the scale-up districts. Through current mechanisms and the SAFE contract, it is expected that 80 percent of this unmet need will be reached by the end of FY 2017. As scale-up districts reach saturation, sustained districts will be evaluated and potentially converted to scale-up districts so that, by 2020, 80 percent of eligible PLHIV across all SAFE districts are receiving ART.

4.2 Tasks

The contractor must implement the following tasks to achieve the objectives and outcomes of SAFE:

Objective 1: Increase access to and utilization of quality HIV/AIDS services.

By 2019, it is expected that Zambia’s ART program will deliver services to approximately one million people. Currently there are over 600,000 people on ART at over 530 sites across the country. Although significant numbers of providers have been trained and the number of nurse prescribers is increasing, alternative models of delivery are necessary. As the growing number of HIV-infected clients continues to outstrip space in secondary and tertiary health facilities, the GRZ is considering moving away from treating HIV/AIDS through acute care services only. The GRZ is also contemplating the introduction of a chronic care model to provide HIV/AIDS services to stable clients. There is a need to improve quality and integrate HIV/AIDS service delivery at the primary health care (PHC) facility level. Measures of improved patient outcomes include, but are not limited to: immunologic recovery; viral suppression, increased TB treatment success rate among PLWHA with active TB; improved patient retention rates, and reduced vertical transmission of HIV and HIV-related mortality and morbidity. The contractor, in coordination with the GRZ, must routinely monitor patient outcome data to ensure that remediation measures for service delivery issues are effectively implemented. The contractor must track remediation measures to resolution.

Outcome 1.1 Improved range of comprehensive HIV/AIDS services in scale-up and sustained districts.

The contractor must provide technical and material assistance to GRZ facilities to enable them to offer an expanded range of high quality, comprehensive HIV/AIDS services. At a minimum, the Contractor must:

Outcome 1.2 Increased quality of HIV services in scale-up and sustained districts.

The contractor must provide technical and material assistance to provincial and district medical offices to improve the quality of decentralized services. At a minimum, the contractor must:

Outcome 1.3 Increased coverage of comprehensive HIV/AIDS services

The contractor must assist the GRZ through technical and material assistance to scale up and sustain high-quality, comprehensive HIV/AIDS clinical care and treatment services at the primary care level, and sustain services at the secondary care level. At a minimum, the contractor must:

Expected Results for Outcomes 1.1 through 1.3:

· Mother-to-child transmission of HIV is reduced to less than five percent in sustained and scale-up districts;

· 80 percent of HIV+ pregnant women enrolled in PMTCT are retained on HIV treatment 24 months after commencement of ART;

· 80 percent of adults aged 15-49 attending in-patient and out-patient services in the scale-up districts get tested for HIV and receive their results;

· 80 percent of HIV-positive clients in scale-up districts receive ART services by 2017;

· 80 percent of HIV-positive clients in all SAFE districts receive ART services by 2017;

· 80 percent of identified HIV-infected children receive HIV treatment;

· 80 percent retention on ART 12 months after commencement of HIV treatment in all supported sites (static and mobile);

· 80 percent of PLHIV in scale-up districts access HIV/AIDS care services;

· 80 percent of all PLHIV in care in scale up districts are screened for TB;

· 90 percent of PLHIV with active TB complete TB treatment;

· 50 percent increase in the number of public health laboratories capable of conducting HIV/AIDS diagnosis and disease monitoring across supported districts;

· 90 percent of supported facilities report through the GRZ structures;

· 90 percent of supported sites implement continuous quality improvement plans;

· 100 percent of supported sites are meeting national waste management standards;

· 100 percent of supported sites are utilizing national infection control standards;

· 100 percent of supported sites for VMMC are meeting national VMMC standards;

· 50 percent increase in the number of HIV negative men provided with VMMC services;

· 100 percent of supported sites have procedures that track remediation from identification of issues to resolution, as per Zambian government standards;

· 90 percent of sites report results to national, provincial and district levels on a monthly, quarterly, semi-annual and annual basis;

· Laboratory support and monitoring systems established and utilized for all supported laboratory services;

· Turn-around times for laboratory results reduced for all facilities; and

· Pharmacy support and management systems established and utilized for all supported pharmacy services.

Objective 2: Improve the capacity of MOH and MCD at the provincial and district levels to provide comprehensive, high-impact HIV/AIDS services.

The contractor must design and implement capacity building activities at the provincial and district levels to facilitate the decentralization of HIV services, improve patient outcomes, and reduce care and treatment lost to follow-up through enhance tracking interventions. These efforts must align with Objective 1 activities and seek to unblock bottlenecks that challenge service delivery efforts at the lower levels of the health system. MOH capacity building activities must be conducted at the workplace, minimize time away from work for participants, and must be coordinated with the USAID Systems for Better Health project.

Outcome 2.1 Strengthened ability to provide decentralized services in scale-up and sustained districts.

At a minimum, the contractor must:

Task 2.1.1: Procure motor vehicles to support GRZ HIV program implementation at the decentralized level;

Task 2.1.1: Undertake targeted renovation of health facilities in order to make them more conducive for the provision high quality HIV prevention, care and treatment services.

Task 2.1.2: Assist MOH with coordination and supervision of clinical HIV services by providing training and technical/logistical support as needed at the headquarters, PMO and DMO levels.

Task 2.1.4: Provide technical and material assistance to build capacity of pharmacy and laboratory management staff;

Task 2.1.5: Provide technical and material assistance to the GRZ to build capacity to manage district and facility level information systems for routine program monitoring. This must include capacity strengthening to improve the collection, analysis and use of HIV service delivery data;

Task 2.1.6: Procure IT equipment and support the placement of data entry clerks to health facilities to facilitate the timely collection and use of HIV service delivery information;

Task 2.1.7: Provide technical and material assistance to the PMOs and DMOs to strengthen capacity to coordinate stakeholders implementing HIV activities in their respective jurisdictions; and Task 2.1.8: The contractor must provide technical and material assistance to PMOs and DMOs to strengthen capacity to provide clinical mentorship and supportive supervision to health facility staff that provide HIV services.

Task 2.1.9: Provide technical and material assistance to the GRZ to roll out national clinical policies during the first year of the contract.

Expected Results:

· Annual plans for provincial and district HIV/AIDS services are developed in 100 percent of supported provinces;

· Routine facility-based mentorship, supervision and oversight established and implemented in supported districts in the six activity provinces; and

· HIV monitoring and reporting systems functional in 100 percent of supported districts.

Outcome 2.2 Transition of key components of SAFE to the GRZ completed

In coordination with the GRZ and USAID’s G2G efforts, the contractor must design and implement activities to strengthen the ability of partner Ministries to eventually take over specific activities initially conducted by the contractor. These may include, but are not limited to, management of routine supervision and mentoring programs, development and roll-out of new clinical policies and guidelines, procurement and maintenance of medical equipment, management of facility level pharmacy services, and management of facility level data information systems for routine monitoring and evaluation.

Table 2. Transition timelines for specific activities

Joint transition planning and execution in coordination with the GRZ and USAID are essential elements of this award. Transition plans and schedules will vary according to the provinces and districts.

Expected Results:

· The GRZ is primarily responsible for activities listed in Table 2 according to the timelines indicated;

· Planning and budgeting for transitioned activities are integrated into district planning, budgeting and processes in 100 percent of supported districts; and

· End-of-project transition plans are implemented in 100 percent of supported districts.

Outcome 2.3 Increased institutional capacity to implement continuous quality improvement and quality assurance programs to improve the quality of comprehensive decentralized HIV/AIDS services in scale up and sustained districts.

The GRZ should have the capacity to sustain quality, comprehensive HIV/AIDS services, as well as ensure a steady supply of ARVs and related commodities to health facilities. The contractor must work with provincial and district offices of the MOH to enhance the ability of each of the supported districts to formulate and implement comprehensive district level work plans and budgets, incorporating performance standards and continuous quality improvement methods, within the first two years of this contract.

The contractor must:

Tasks 2.3.1: Provide technical and material support to MOH to assure that national quality standards, policies and guidelines are being met/followed (Decentralized Level); and Task 2.3.2: Provide technical and material assistance to the GRZ to ensure that service delivery sites meet and maintain accreditation criteria as stipulated by the Health Professions Council of Zambia.

Expected Results:

· Continuous quality improvement plans implemented in 100 percent of scale-up and sustained districts by the end of year two of the contract; and

· Responsibility for maintaining CQI efforts transitioned to GRZ by the end of year two of the contract.

Objective 3: Integrate family planning services into all HIV/AIDS service programs in the six supported provinces.

Despite family planning availability in all clinical settings in Zambia as part of primary health care, reproductive health, and maternal newborn and child health care, family planning is not well integrated with HIV services.

Outcome 3.1 Increased access to family planning services at facilities providing HIV/AIDS services.

The contractor must:

Expected Results:

· Increased access to family planning services through the HIV/AIDS platform;

· Family planning services delivered in 100 percent of PMTCT sites; and

· 100 percent of supported HIV treatment facilities have fully integrated family planning services.

Objective 4: Improve the health and well-being of PLHIV through improved NACS services Nutrition and food security are vital to improving and maintaining the health of PLHIV. Infection with HIV increases an individual’s energy and nutrient requirements. Malnutrition accelerates the progression from HIV to AIDS and leaves PLHIV more vulnerable to opportunistic infections that further compromise their health and well-being. Poor nutrition also affects the efficacy of antiretroviral drugs and the adherence of PLHIV to those drugs.

Services that identify and address malnutrition in PLHIV are most effective when integrated into existing HIV treatment and care systems. Multiple studies have established clinical malnutrition as a risk factor for HIV progression and mortality for patients prior to the initiation and during the course of ART. Clinical malnutrition can also cause poor birth outcomes among HIV positive pregnant women, and high morbidity and mortality among OVC, especially those five years of age or younger. In addition, there is an extensive body of research recognizing that a strong correlation exists between nutritional care and the efficacy of HIV/AIDS anti-retroviral drugs (ARVs). The positive effect of the provision of NACS including both supplementary and therapeutic foods for malnourished PLHIV is well documented. According to WHO, the human body’s energy requirements are increased by 10% in HIV positive asymptomatic adults. This is increased 20-30% in symptomatic adults and as much as 50-100% in infected children with growth faltering, while dietary protein levels should be maintained at 12-15% of total energy intake. This is because HIV progressively damages the immune system, which can lead to weight loss and diarrhea. HIV-related conditions can also lower food intake by reducing appetite and interfering with the body's ability to absorb food. HIV alters the body’s metabolism, which leads to increased energy and nutrient requirements.

Outcome 4.1 Improved NACS service delivery at the facility and community levels.

In coordination with USAID’s G2G mechanism, the contractor must support the MOH, and the Ministry of Agriculture (MOA) through technical assistance to improve the operationalization of NACS by ensuring that GRZ personnel are familiar with the implementation of NACS. The contractor must place emphasis on pre- and in-service training of health personnel including doctors, nurses, midwives, clinical officers, pharmacists and nutritionist. Concurrent to this capacity building approach, the USAID/GRZ G2G mechanism will provide resources to the GRZ to purchase anthropometric equipment, nutritional supplements, water purification methods, print training manuals, wall charts and guidelines, as well as hire staff. The contractor must:

Task 4.1.1: Provide material and technical assistance in updating guidelines, wall charts and training materials, including printing during the first year of the contract Task 4.1.2: Provide logistics and administrative assistance to the GRZ to improve coordination between MOH, MOA, and implementing partners at national, provincial, district and community levels;

Task 4.1.3: Integrate NACS monitoring and evaluation systems into patient records and the continuum of care.

Task 4.1.4: Develop and implement a capacity building plan for the National Food and Nutrition Commission (NFNC) to plan, implement and monitor HIV nutrition activities, including data quality audits for NACS services;

Task 4.1.5: Procure and deliver vitamin fortified high energy protein supplements (HEPS) and ready-to-use therapeutic feed (RUTF) according to WHO standards for RUTFs and Zambian Bureau of Standards for HEPS for the first two years of the contract, after which time the GRZ will become primarily responsible with support through G2G funding.

Task 4.1.6: Provide on-the-job training, coaching and mentoring of facility and community based healthcare workers on the provision NACS;

Task 4.1.7: Integrate NACS into pre-service training at Zambian colleges and universities;

Task 4.1.8: Advocate for increased budget allocations for nutrition activities with relevant ministries; and Task 4.1.9: Update and adapt Information Exchange Communication (IEC) and Behavior Change Communication (BCC) materials for HIV and nutrition.

Outcome 4.2 Integration of NACS services into HIV/AIDS care and support.

In collaboration with the GRZ, the contractor must improve adherence and retention of HIV patients to ART by executing the following tasks:

Task 4.2.1: Provide coaching, mentoring and on-the-job training to GRZ facility level staff on nutrition specific medical diagnostics and treatment of PLHIV, including nutrition assessment and management;

Task 4.2.2: Provide coaching, mentoring and on-the-job training to GRZ facility level staff on nutrition assessments and patient categorization for all clients that seek ART services;

Task 4.2.3: Provide coaching, mentoring and on-the-job training to Community Health Workers (CHWs) to counsel PLHIV on self-management support;

Task 4.2.4: Provide coaching, mentoring and on-the-job training to CHWs so that they can provide intensified behavior modification counseling to PLHIW;

Task 4.2.8: Develop and implement a community based matching program between community volunteers to NACS clients to improve adherence to care and treatment;

Task 4.2.9: Develop and implement referral and service enrollment systems for NACS client to access agricultural support, economic strengthening, food security, and social support programs.

Expected results from 4.1 and 4.2:

· 90% of NACS services are implemented in SAFE facilities and…