01-18284. Improving the Quality of HIV/AIDS Care in the Republic of Zimbabwe; Notice of Availability of Funds

A. Purpose

The Centers for Disease Control and Prevention (CDC) announces the availability of fiscal year (FY) 2001 funds for a cooperative agreement with the University of Zimbabwe (UZ), School of Medicine, Clinical Epidemiology Unit(CEU) for improving the quality of health care services for HIV/AIDS and of related clinical preventive services in the Republic of Zimbabwe.

The U.S. Government seeks to reduce the impact of HIV/AIDS and related conditions in specific countries within sub-Saharan Africa, Asia, and the Americas through its Global AIDS Initiative. Through this initiative, CDC's Global AIDS Program (GAP) aims to strengthen capacity and expand activities in the areas of (1) HIV primary prevention; (2) HIV care, support, and treatment; and (3) capacity and infrastructure development, especially for surveillance. Targeted countries represent those with the most severe epidemics and the highest number of new infections. They also represent countries where the potential for impact is greatest and where U.S. Government agencies are already active. Zimbabwe is one of these targeted countries.

To carry out its activities in these countries, CDC is working in a collaborative manner with national governments, non governmental organizations (NGOs), other national and international agencies to develop programs of assistance to address the HIV/AIDS epidemic. CDC's program of technical assistance to Zimbabwe focuses on several areas including strengthening surveillance and laboratory measures, scaling up promising prevention and care strategies, supporting behavior change communication projects, promoting technology transfer, and other capacity building efforts.

Zimbabwe is experiencing one of the world's most severe AIDS crises that looms as a disaster of unprecedented proportions. Zimbabwe has one of the world's highest HIV prevalence rates among adults, life expectancy has declined from 63 years to 38 years in only a decade, and the proportion of children orphaned by AIDS is expected to reach 35 percent by 2010.

The need for appropriate, quality health care corresponding to the generalized epidemic of HIV/AIDS in Zimbabwe is enormous. Approximately 2 million of the 12 million Zimbabweans are infected with HIV. An estimated 60 percent of hospital inpatients in Zimbabwe suffer from HIV-related conditions, and more than 2,000 deaths per week result from AIDS. A recent burden of disease assessment in Zimbabwe found that nearly 45 percent of all lost disability-adjusted life years (DALYs) in Zimbabwe can be attributed to HIV/AIDS. Tuberculosis rates have increased 10-fold since the mid-1980s, and the World Health Organization(WHO) now lists Zimbabwe as having the highest estimated incidence rates of tuberculosis in the world at more than 500 new cases/100,000 population annually. Despite the tremendous stress on hospitals from the high proportion of patients suffering from HIV-related conditions, the majority of persons diagnosed with or suspected as suffering from HIV/AIDS related conditions in Zimbabwe have in fact been discharged to either self care or systems of “community and home-based care,” services that may range from quite helpful to being of very little help.

In response to HIV/AIDS, Zimbabwe has taken many positive steps. It was one of the first governments in the world to negotiate a large World Bank loan for AIDS prevention in 1992. In December 1999, the Government of Zimbabwe (GOZ) declared AIDS a national disaster, created a new ministerial-level multi-sectoral National AIDS Council (NAC), announced a new National AIDS Policy, and instituted an “AIDS levy” payroll tax to underwrite improved national AIDS prevention and care services.

The national response has also included many examples of creative programming and successful grassroots initiatives in the face of staggering adversity. Many of these grassroots initiatives were in the domain of home-based care and support for persons living with HIV/AIDS (PLWA). Several excellent evaluations of home-based care for PLWA have been conducted in Zimbabwe at specific points in time. However, no consistent focus or organizational entity has been established that is dedicated to systematically monitoring, evaluating, and attempting to improve the quality of care for HIV/AIDS across all levels of the health system and society, from central hospitals to community and home-based care programs. The AIDS and TB Unit of the Ministry of Health and Child Welfare (MOHCW), which is responsible for public sector health care for HIV/AIDS within the Ministry, has only one physician, who also oversees all health sector aspects of HIV/AIDS prevention and care, as well as all governmental programs for STDs and TB. Therefore, the MOHCW critically needs allied organizations that can assist in coordinating and implementing a broad range of activities to improve quality and coverage of care for HIV/AIDS and related conditions.

The Clinical Epidemiology Unit (CEU) at the University of Zimbabwe (UZ) School of Medicine was established in 1989, after training of an initial cadre of clinical epidemiologists in the United States and Australia. Supported through the International Clinical Epidemiology Network (INCLEN) by the Rockefeller Foundation (until 1992) and by Australia AID (from 1994 to 2001), the UZ CEU has trained 16 persons in clinical epidemiology (including 7 currently in training), 3 in Health Social Science, 3 in Biostatistics, 2 in Health Economics, and 3 in Pharmaco-epidemiology. This diversity and extent of training in clinical epidemiologic disciplines is superimposed on an underlying further diversity of clinical specialties represented in the UZ CEU, including internal medicine, pediatrics, obstetricians, surgeons, laboratory scientists, health social scientists, biostatisticians, pharmacists, and others.

For the past 7 years, clinical epidemiology training at UZ has been supported by the University of Newcastle-Australia through technical assistance, distance learning curriculum, and teaching technology. Over the past several years, the CEU petitioned for and has received approval from the University of Zimbabwe to offer a local Masters training program in Clinical Epidemiology, beginning in 2001. The UZ CEU has been solicited by the World Health Organization (WHO) to offer this degree training program to qualified candidates from other countries in the Region, who will be supported by WHO to be trained at the UZ CEU. The UZ CEU is the only existing organizational entity in Zimbabwe with the overall mission, structure, and multidisciplinary capacity to develop the proposed Quality of HIV/AIDS Care Initiative, while simultaneously supporting it through a degree-granting training program in clinical epidemiology.

The purpose of this cooperative agreement is to contribute systematically and strategically to improving the quality of HIV/AIDS care in Zimbabwe, and related clinically-oriented prevention services (such as prevention of mother-to-child-transmission (PMTCT) of HIV infection), with a focus on care at the district hospital level and below. Since the needs for HIV/AIDS care and clinical prevention services will intensify over time, a second and related purpose is to train more clinical epidemiologists in Zimbabwe and support them to systematically address priority issues in HIV/AIDS clinical care that will inevitably arise over the coming decade. This will be accomplished through cooperation between CDC and the Clinical Epidemiology Unit, University of Zimbabwe School of Medicine, in collaboration with relevant policy-setting authorities such as the MOHCW and the National Drugs and Therapeutics Policy Advisory Committee (NDTPAC). These collaborative activities are expected to contribute meaningfully, immediately, and over the coming decade to assist Zimbabwe to develop tools needed to increase the quality and coverage of HIV/AIDS clinical services.

B. Eligible Applicants

Assistance will be provided only to the University of Zimbabwe, School of Medicine, Clinical Epidemiology Unit (CEU). No other applications are solicited.

The UZ/CEU is the only appropriate and qualified organization to fulfill the requirements set forth in this announcement because:

1. As an established inter-departmental unit organized around the cross-cutting discipline of clinical epidemiology, the CEU is uniquely positioned to bring together faculty of the School of Medicine (and other faculty within the University of Zimbabwe) to design and implement a systematic program of clinical epidemiologic investigation, systematic reviews, support for guidelines development, and related activities to support an initiative to improve the quality of HIV/AIDS care in Zimbabwe. The development of the CEU with its generalist focus on clinical epidemiology as a core discipline has now been successfully implemented, and has resulted in a committed, enthusiastic and capable faculty.

2. The UZ/CEU is the only entity in Zimbabwe, and one of the few in Africa, that offers training leading to a master degree in clinical epidemiology. Since the Quality of HIV/AIDS Care Initiative is a long-term endeavor that depends critically on building up human capacity in Zimbabwe for assessing and improving the quality of clinical care for HIV-related conditions, the CEU is the only potential applicant able to be responsive to this critical need to generate trained manpower in the domain of clinical epidemiology to address continually emerging issues in HIV/AIDS care that will confront Zimbabwe over the coming decade.

3. Candidates for the Master of Clinical Epidemiology degree all conduct investigations and write theses on some aspect related to quality, cost-effectiveness, or other properties of clinical care in Zimbabwe. To the extent that these trainees can be guided by a carefully derived, coordinated set of key health services questions related to increasing quality and coverage of HIV/AIDS care, and supported specifically by resources dedicated to addressing that agenda, this pool of Masters trainees, with their CEU mentors, constitutes an immediately available reservoir of human resources available to quickly begin addressing high priority issues in HIV/AIDS care.

C. Availability of Funds

Approximately $500,000 is available in FY 2001 to fund this agreement. It is expected that the award will begin on or about September 30, 2001 and will be made for a 12-month budget period within a project period of up to five years. Annual funding estimates may change. Continuation awards within the approved project period will be made on the basis of satisfactory progress as evidenced by required reports and the availability of funds.

Direct Assistance

Direct provision of equipment and supplies (e.g., vehicles, computer hardware/software, specific consumables & supplies) may be requested as direct assistance in lieu of a portion of this financial assistance.

Use of Funds

Funds received from this announcement may not be used for the purchase of the direct purchase of drugs for the treatment of active TB disease. Funds may not be used for new construction, although limited renovation of existing space may be acceptable.

Funds received from this announcement will not be used for the purchase of antiretroviral drugs for treatment of established HIV infection (with the exception nevirapine in PMTCT cases and with prior written approval), occupational exposures, and non-occupational exposures and will not be used for the purchase of machines and reagents to conduct the necessary laboratory monitoring for patient care.

Applicants may contract with other organizations under these cooperative agreements, however, applicants must perform a substantial portion of the activities (including program management and operations and delivery of prevention services for which funds are requested).

The costs that are generally allowable in grants to domestic organizations are likewise allowable to foreign institutions and international organizations, with the following exceptions:

Indirect Costs: With the exception of the American University, Beirut, the Gorgas Memorial Institute, and the World Health Organization, indirect costs will not be paid (either directly or through a sub-award) to organizations located outside the territorial limits of the United States or to international organizations regardless of their location.

All requests for funds, including the budget contained in the application, shall be stated in U.S. dollars. Once an award is made, the Department of Health and Human Services (DHHS) will not compensate foreign grantees for currency exchange fluctuations through the issuance of supplemental awards.

No funds appropriated under this Act shall be used to carry out any program of distributing sterile needles or syringes for the hypodermic injection of any illegal drug.

D. Where To Obtain Additional Information

This and other CDC announcements can be found on the CDC home page Internet address—http://www.cdc.gov. Click on “Funding” then “Grants and Cooperative Agreements.”

If you have questions after reviewing the contents of all the documents, business management technical assistance may be obtained from:

Dorimar Rosado, Grants Management Specialist, Grants Management Branch, Procurement and Grants Office Centers for Disease Control and Prevention Room 3000, 2920 Brandywine Road, Atlanta, GA 30341-4146, Telephone: [phone], E-mail: [e-mail]

For program technical assistance, contact:

Michael St. Louis, MD, Global AIDS Program (GAP), Zimbabwe Country Team, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention (CDC), Zim-CDC AIDS Project Team, 38 Samora Machel Avenue, 2nd Floor, Harare, Zimbabwe, Tel: [phone], 796048, Fax: [phone] E-mail: [e-mail]

Dated: July 17, 2001.

John L. Williams,

Director, Procurement and Grants Office, Centers for Disease Control and Prevention (CDC).