USAID/Zambia Grant for Community-Based Prevention Initiative for Vulnerable Populations in Zambia

Subject to the availability of funds, the planned competitively awarded Cooperative Agreement(s) shall be for period of three years and shall focus on prevention engagements at the community level to include care and support of OVC and other at-risk groups, and in building Zambian capacity to manage, implement and fund such programs sustainably in the future with decreased or no outside funding. The Agreement(s) shall be outcomes based and focused on results.

CONCEPT PAPER
Community Based Prevention Initiative for Orphans and Vulnerable Children (OVC), Youth, and other Vulnerable Populations

Goal: Provide broad and effective support for Zambian-led HIV prevention and behavior change initiatives which reduce HIV transmission; help Zambia develop greater capacity to care for and support orphans and vulnerable children (OVC), at-risk youth, and the 85% of Zambians who are HIV negative, but at risk of infection, as well as the 15% of Zambians already infected with HIV/AIDS.

Approach: This program envisions a new scalable strategy focused on prevention themes. It will equitably address target populations including OVCs, and both HIV positive and HIV negative populations. Targeting approaches proposed by applicants should include measures to address and measure effectiveness and equitable distribution or resources and program activities.

Expected Award Mechanism: Cooperative Agreement (with one or more award possible)

Illustrative Funding and Period of Performance: $40-60 million for three years.

Purpose:
1) Prevention: To provide broad, effective support to Zambian national HIV prevention and behavior change efforts through community-based interventions, to: a) prevent HIV infection of the 85% of Zambians who are HIV-negative; as well as b) prevention with positives for the 15 % of Zambians who are HIV-positive, delivered to and through families, couples, individuals or appropriate group structures. The goal for all Zambians is to reduce risk behaviors through effective, evidence-based prevention activities equitably targeting both HIV-negative and HIV-positive persons;

2) Care and Support for OVC and Other At-Risk Groups: To promote community engagement in providing essential care and support on an individual/family basis, in both home and community settings, to target groups designated in the Reauthorization Act of 2008, including OVC, youth, and other at-risk groups, including those already infected with HIV;

3) Improved Economic Opportunity Provided Equitably to all Zambians at Risk: Program interventions will follow the strategy described above to provide access to greater and more sustainable, market-oriented, demand-driven, and equitable economic opportunities for all Zambians placed at risk or made vulnerable by HIV/AIDS. Target groups will include those facing the greatest economic hardships, including orphans and vulnerable children, youth, and other at-risk groups, such as those at risk of infection, and those already infected.

Anticipated results of such economic opportunity will be greater economic security including reduced vulnerability and exploitation, and decreased dependency, of OVC, youth, others at risk of infection, or those already infected, to enable them to become productive and self-sufficient citizens. A key element of the targeting strategy will be to provide access to economic opportunity on a more equitable basis. HIV-positive status will not be the sole basis for either inclusion, nor will it be the basis for exclusion from economic support.

4) Zambianization: To rapidly identify and aggressively strengthen appropriate local structures (government, private sector, faith and community based) while building Zambian human capacity. Zambians should partner as fully as possible in the design and launch of program activities. They should then proceed to take over during the life of the project, and finally to carry on beyond the life of the expected agreement, with decreased or no external support.

Rationale: Given progress thus far in slowing the spread of HIV in Zambia, and in scaling up and delivering HIV-related services to those already infected, the Government of the Republic of Zambia (GRZ) and the United States Government (USG) have determined that prevention is the highest ranking objective for this and many other HIV-related programs. The strategic aim will be to gain control of the HIV epidemic through focused interventions targeting those most likely to transmit/acquire the infection. Greater community engagement will strengthen prevention-oriented care and support for OVC, youth, people at-risk, and those already infected.

Proven, effective prevention engagements will be the priority under this program. A prevention lens is further required in the design and implementation of other supporting interventions. These types of additional interventions may include strategically-designed prevention-oriented care and support activities delivered in community and home settings, for the 85% of Zambians who are HIV negative, as well as OVC, at-risk youth, other people at-risk and those already infected. Target groups will access an effective, equitable combination of prevention-oriented care and support, including “prevention for HIV negatives” as well as “prevention with positives” services to decrease both horizontal and vertical HIV transmission. Revised community-based counseling and testing strategies and services will have two functions: a) Counselors will determine the risk profile of the 85% of clients who test HIV-negative, and refer those most at risk for behavior change and other support; and b) counselors will link HIV+ clients directly to Positive Living Groups for further, intensive behavior change interventions.

Individual OVCs, people at-risk and those already infected and their families need access to necessary, appropriate care and support, consisting of cost-effective package of essential preventive care services. Such services should be in line with the current policy dialogue, emerging trends and government strategies in Zambia and should also take into account the Office of the Global AIDS Coordinator (OGAC) adult and pediatric “Preventive Care” package approaches and recommendations noted on the website for the President’s Emergency Plan for AIDS Relief (http://www.pepfar.gov)
Children’s package: http://www.pepfar.gov/guidance/78263.htm
Adult package: http://www.pepfar.gov/guidance/78258.htm

The overall effect will be a series of paradigm shifts. The first shift will be away from care & support efforts in which prevention is a separate or subordinate activity, or in which services and resources are inequitably reserved for those who are already infected, to prevention-oriented care and support efforts in Zambia and which are also equitably allocated among Zambians who are HIV-negative and HIV-positive. The second paradigm shift will be to transfer responsibility for palliative care increasingly from donors to the government and people of Zambia, who must configure such care to be sustainable without external support. A third shift is to emphasize that from the USG Zambia perspective, care and support must contribute to a comprehensive prevention effort, rather than consisting as an aim in itself, with no preventive role.

Activities are expected to be implemented increasingly, then predominantly and ultimately entirely through local entities, with decreasing external management oversight, as required to ensure program quality, accountability, and compliance.

Illustrative activities and/or milestones:

Community engagement for prevention-oriented care and support for orphans and vulnerable children and other at-risk youth: The key concepts are prevention orientation and community engagement. Activities will take place both in the home and in community setting targeting at-risk youth and people at-risk, and those already infected to increase prevention efforts thereby decreasing the number of new infections.

Equitable allocation of care and support for the 85 % of Zambians who are HIV-negative (people at risk) as well as the 15% who are already living with HIV/AIDS: The priority will be on effective community-based prevention with HIV-negative as well as HIV positive individuals, as well as on deploying the recommended OGAC adult and pediatric “preventive care” packages as discussed above. For HIV-negative Zambians, the key will be to provide behavior change support to those identified as most at-risk for HIV infection.

For all Zambians at risk, which includes HIV-positive and at-risk negative individuals, and their families, preventive packages could contain condoms, long-lasting insecticide treated malaria bed-nets, water purification products, and an antibiotic to prevent opportunistic infections. Care approaches may, but need not, include a comprehensive adult and pediatric palliative care package to help individuals/families maintain immunity, change behavior, and delay the start of anti-retroviral therapy. The cooperative agreement may allow the awardee to accept U.S. family planning (FP) funds, subject to availability of funds, and thus to offer FP services. Otherwise, the awardee may refer interested clients for FP services to reduce the rates or risk of HIV infection of infants.

Promoting “Zambianization”:
o Greater involvement of the private sector, i.e., through public-private partnerships (Illustrative Milestones: # and value of public private partnerships, growing annually);

o Better align with and support GRZ efforts to respond to HIV/AIDS (Illustrative Milestones: GRZ training guidelines and standards, and GRZ certification of volunteer caregivers, integration of GRZ Community Health Workers (future));

o Increased use of local expertise (Illustrative Milestones include recruiting, hiring, training, and promoting Zambian staff into key positions);

o Increased service delivery by local organizations – including private sector, GRZ and local groups. (Illustrative Milestones: transition plans, local partners, building capacity, and progress in transferring activities to local partners).

Sustainable and equitable employment opportunities: Reauthorization language prioritizes reducing the economic vulnerability of women/girls, and other groups that are at risk of HIV infection because of their economic dependency. Applicants will propose implementation and replication of effective, demand-driven, equitable economic growth/employment opportunities, particularly those targeting at-risk groups, including women and girls, and OVC, but also other Zambians who at risk of infection primarily for economic reasons.

Activities could include economic growth opportunities targeting women and girls, OVC, other at-risk youth, and other adults at risk, as well as those already infected to reduce their HIV vulnerability and dependency on others. NOTE: Activities supporting increased economic opportunities will link closely with programs funded under other, complementary USG awards.

Cross Cutting and Ongoing Activities:
o Joint work planning: Carry out joint work planning and develop on-going coordination mechanisms with other relevant programs, including but not limited to the anticipated HIV community-based prevention contract, local services contract, other USG and Cooperating Partner funded efforts to ensure total complementarity of activities at all levels of implementation.

o Ongoing Analyses and Project Modification: Conduct and document regular and on-going analysis to determine how increased income relates to or influences risk behavior and higher rates of HIV infection. Modify economic growth activities in response. Implement interventions to reduce income-related HIV-risk behaviors. Note: Short analytical analysis is anticipated rather than long-term longitudinal studies.

o Technical Working Groups and Theme Groups: Active, consistent participation in Government of Zambia, National AIDS Council and/or other technical working groups and theme groups on relevant issues.

Illustrative Annual Targets: (Reauthorization language requires annual targets. Cumulative annual PEPFAR targets would come from all awards funded under this Request for Applications)
>250,000 or more orphans and vulnerable children receive effective care and support that includes targeted HIV prevention messages and activities (any increase in current OVC target numbers TBD).
>100,000 people living with HIV/AIDS receive prevention-focused care and support services, including PWP, and preventive care packages.
Additional targets to be developed

Outcomes: The project will achieve measurable and significant improvements in terms of
A high percentage of the 85% of Zambians who are HIV-negative remain HIV-free
HIV positive Zambians access anti-retroviral therapy in a timely way to reduce risk of HIV transmission to others
HIV positive Zambians change risk behavior to avoid infecting others and to protect themselves
OVC and youth learn and adopt safe and healthy behaviors to avoid HIV infection
OVC, youth and other at-risk populations equitably gain access to viable economic opportunities and income security.
Community-based care and support activities transition from USG funding to Zambian and other sources
Zambians assume a larger percentage of key roles in the local response to HIV/AIDS
Sustainability increases significantly and measurably in terms of agreed-on indicators