Consultancy, Impact Evaluation of Differentiated Models of Care for Adolescents Living with HIV in Botswana

Botswana country Office is looking to source a consultant to generate quantitative and qualitative evidence on the impact of differentiated models of care on the health and well-being of adolescents living with HIV in Botswana.

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BACKGROUND

HIV continues to have a tremendous impact on the lives of adolescents in Eastern and Southern Africa (ESA). AIDS is one of the leading causes of death among adolescents, and over half (53 per cent) of all new HIV infections among adolescents globally occurred in the region. There are 1.1 million adolescents aged 10-19 years living with HIV in ESA. It is estimated that up to 70 per cent of adolescents living with HIV were infected vertically and have been living with the virus, often without treatment, for many years. At the end of 2015, only 6 out of 10 children aged 0-14 living with HIV in ESA were receiving antiretroviral therapy (ART). Comparable numbers are not readily available for adolescents, but are thought to be even lower, given the unique characteristics of this age group and the insufficient priority placed on adolescents in the HIV response to date.

In Botswana, adolescents represent (20.6%) of the total population and are one of the most vulnerable groups for HIV infection and AIDS related deaths. The last two HIV&AIDS household surveys (BAIS 2008 and 2013), as well as the 2016 Botswana Youth Behavioral and Biological Surveillance Survey among 13-19 year old students suggest worrying and negative trends in behavior among adolescents and young people. HIV prevalence among youth 15-24 remains high at an estimated 7.9% with strong gender disparity. Currently, it is estimated that 17,000 adolescents are living with HIV in Botswana, with approximately 50% of young people (10-24) currently not on treatment. Each week, 74 youth (15-24) are newly infected with HIV, majority of infections among girls.  Comprehensive knowledge of HIV remains low, condom use among sexually active youth (15-24) is declining, forced sex is high, and extremely high teenage pregnancy rates continue to be reported.

Justification/purpose of assignment:

Adolescents Living with HIV (ALHIV) have to contend with challenges related to growing up with HIV infection while faced with the developmental tasks of this phase of life including stigma and discrimination; problems with long-term adherence to treatment (ART); stress, anxiety and other mental health issues; disclosure of HIV diagnosis to others including sexual partners and the need to prevent further transmission of HIV; sexual and reproductive health decisions; poor academic performance and school achievement with a potential long-term effect on employability, income and wellbeing; and  challenges associated with transitioning from health services provided in pediatric HIV care settings to adult HIV care systems and assuming increased responsibility for their own care.

While the number of peri-natally and behaviorally infected HIV infected adolescents has generally increased, information and services which are focused on the health, wellbeing and quality of life of this population is still missing. Adolescent focused interventions are still limited within national HIV responses, and concerted efforts from the health sector and communities are needed to remedy this gap. Although disclosure, safer sex, family planning, cervical cancer screening, teen pregnancy and parenting become pressing concerns at this age, they are not adequately addressed by pediatric and adult services. Furthermore, sexual and reproductive health (SRH), mental health, treatment adherence and school related needs of adolescents living with HIV remain largely unaddressed.

Adolescents continue to face service access barriers including: lack of knowledge of available services and or rights; low service seeking behaviors; clinic related barriers including (attitudes, skills and knowledge gaps of health care providers to provide adolescent specific services); limited/incomplete referrals from community based service providers (teachers, social workers and psychologists) to health facilities; unavailability or long distance to peer support services e.g. teen clubs; and unavailability of adolescent friendly/stand-alone treatment and care services at some government health facilities. Currently, few HIV positive adolescents outside of large urban areas are receiving care and psychosocial support. Developing sustainable and cost effective programmes that effectively respond to the needs of this cohort and can be implemented at scale is therefore critical.

It is against this reason that the Ministry of Health and Wellness is currently working together with UNICEF and Baylor Botswana to design and pilot test differentiated models of care for adolescents living with HIV. The proposed project will include intervention and evaluation components. The intervention will involve implementation of differentiated models of care targeting adolescents and young people living with HIV receiving services within government run health facilities in four districts (Boteti, Ghanzi, Selibe Phikwe and Tutume). The project will run over the course of three years and will be rigorously evaluated to find out how and to what extent differentiated models of care integrated within government run health programmes can positively impact adolescent well-being and their transition to adulthood. Lessons learnt will inform future iterations of programming for ALHIV and provide guidance on cost effective interventions that can be implemented at scale. As such, UNICEF is recruiting a lead research consultant for the impact evaluation. This TOR specifically relates to the evaluation component. The intervention will be carried out by Baylor Botswana, in collaboration with Ministry of Health and Wellness and UNICEF.

Specific Tasks/objectives:

The current proposal with MoHW, UNICEF and Baylor aims to implement sustainable and differentiated models of care for adolescents living with HIV and to provide rigorous evidence on the impact of the intervention on adolescent well-being and their transition to adulthood.  The proposed intervention will include a strong research and evaluation component and will have measures in place to assess the quantity and quality of programme results. A costing exercise will be undertaken so that government knows what the activity will cost when implemented at scale.

The lead research consultant will work in close collaboration with the Ministry of Health and Wellness, Baylor Botswana and UNICEF to develop the research proposal and evaluate the differentiated models of care, including costing out the different service delivery models. This will include development of research protocol, survey instruments, oversight for the field work, (baseline, mid-line and end-line), data analysis, as well as collection of costing and process data. Should additional expertise be required for the costing, the lead consultant will be responsible for identifying such expertise. This TOR does not include data collection. Data collection (field work) will be done through a separate agreement. 

The Primary Research Question to be answered is;

1) To what extent do HIV positive adolescents randomized into the differentiated care models (i.e., a plus component integrated within government run health programmes) show greater improvement in well-being (treatment outcomes, academic performance, co-morbidities, reduced risk behaviors etc.) at 1-year and 2 years post-baseline compared to HIV positive adolescents receiving the current standard care?

Primary Outcomes:

• Viral load suppression rates
• Lost to follow up rates/mortality rates
• Depression
• Prevalence of HIV risk reduction behaviors

Secondary Outcomes:

• Pregnancy rates
• Prevalence of STIs
• Health related quality of life
• Academic Performance
• Substance Use
• Suicide
• Social Support
• Self esteem

Exploratory research questions:

2) How and to what extent can a "plus component" integrated within government run health programmes positively impact adolescent well being and the transition to adulthood vis a vie government run programme with limited NGO role?

(3) What is the minimum core package of interventions required to have positive impact on adolescent well-being?

The consultancy will cover 3 work phases:

Phase I - development of methodology and design of an evaluation to assess the different service delivery models of differentiated care taking into account the different standard and intervention arms as described above. Evaluation should include baseline, midline and follow-up surveys conducted between April 2018 and April 2020.

Phase II - Implementation of the evaluation in the participating districts and facilities and during the stipulated time periods.

Phase III - Assess the cost of the different service delivery models

Methodology and technical approach:

Phase I: Development of methodology and design of an evaluation to assess the different service delivery models of differentiated care (Research Protocol and Survey Development).

• Using a randomized control design, determine the appropriate level of randomization (adolescents, health facilities or community) and process of randomization
• Determine the sample size and sampling procedures for the different arms of the evaluation
• Develop data collection tools to assess the feasibility of implementing the differentiated care models and assess primary and secondary outcomes at baseline, midline and follow-up.
• Determine the sample of facilities that will be participating in the project and randomize them into the control and intervention arms of the evaluation.
• Develop a method to assess the cost of the different service delivery models
• Obtain ethical approval prior to fieldwork implementation

Phase II: Implementation of the evaluation in the participating districts and facilities and during the stipulated time periods.

• Conduct a baseline survey at the start of the project (April - August 2018) to determine level of agreed upon indicators, assess that all components of the different service delivery models are in place to facilitate implementation and level of participation in the project in the different arms of the intervention.
• Conduct a midline survey in April - August 2019 to assess implementation of the different service delivery models of differentiated care. This should take into account the feasibility of each service delivery model within the context of Botswana (resource-constrained). Assess at this point any change in the outcome indicators.
• Conduct a follow-up survey in April - August 2020 to determine any changes in the outcome indicators for the differentiated care models delivered through the various models.

Phase III: Determine the cost of implementing the differentiated care model through the various service delivery models.

• Through the developed costing method, assess the cost of the various service delivery models and coupled with outcome indicators determine the cost-effectiveness of each model in delivering differentiated models of care.

Expected Deliverables and Timeline.

This consultancy will focus on Year 1 deliverables, with options for extension of contract for subsequent years.

Supervisor/overall responsibility:

The consultant will be supervised by UNICEF Botswana Team consisting of the HIV/AIDS Specialist and Monitoring and Evaluation Officer. All work will be done in collaboration with Ministry of Health and Wellness, Baylor Botswana and participating districts and facilities.

Administrative Issues and Conditions:

1. The consultant will use own equipment to produce deliverables. Office space will be provided at UNICEF as available and necessary.
2. The consultant is expected to travel and work in-country and remotely based on an agreed upon schedule. Timing for visits and planning will be jointly agreed with UNICEF Botswana Country Office. The consultant is required to indicate an all inclusive fee for this assignment, taking into account travel to Botswana and in-country travel as applicable. Airfares and in-country living expenses based on existing UN rates, will therefore be part of the all-inclusive fee. Skype calls with country partners to be scheduled based on need.
3. As per UNICEF DFAM policy, payment is made against approved deliverables. No advanced payment is allowed unless exceptions against bank guarantees, subject to a maximum of 30 percent of the total contract value, in cases where advance purchases, for example for supplies or travel maybe necessary.
4. The candidate selected will be governed by and subject to UNICEF's General Terms and Conditions for individual contracts.

To qualify as an advocate for every child you will have…

• Advanced degree (Masters or higher) in Social Science, Public Health or related field.
• At least 8 years experience of conducting research in HIV and AIDS or related field (including research on sensitive issues among adolescents and youth).
• Experience with the deployment, oversight and management of research teams.
• Demonstrated experience in ethical research practices.
• Solid understanding of issues faced by adolescents and young people living with HIV, youth risk behaviors in Botswana and/or Eastern and Southern Africa.
• Demonstrated experience conducting social science or public health research, with expertise in sampling, evaluations and longitudinal study designs.
• Proven record in delivering timely, quality results.
• Demonstrated ability to produce high quality datasets.
• Demonstrated ability to produce high quality reports in English.

For every Child, you demonstrate…

UNICEF’s core values of Commitment, Diversity and Integrity and core competencies in Communication, Working with People and Drive for Results.

View our competency framework at

http://www.unicef.org/about/employ/files/UNICEF_Competencies.pdf

UNICEF is committed to diversity and inclusion within its workforce, and encourages all candidates, irrespective of gender, nationality, religious and ethnic backgrounds, including persons living with disabilities, to apply to become a part of the organization.

Remarks:

Mobility is a condition of international professional employment with UNICEF and an underlying premise of the international civil service.

Only shortlisted candidates will be contacted and advance to the next stage of the selection process.