TERMS OF REFERENCE- GRAND EVALUATION UK PrEP

OVERVIEW

The Elton John AIDS Foundation is seeking a research agency or research consultant to commission an independent evaluation of the "UK PrEP" initiative, inclusive of two grants implemented in London and Liverpool (England).

ABOUT THE ELTON JOHN AIDS FOUNDATION

At the Elton John AIDS Foundation, we believe that AIDS can be beaten. Committed to overcoming the stigma, discrimination, and neglect that fuels the spread of HIV, we harness local expertise and mobilize networks of generous public and private supporters and partners to build love, compassion, and dignity for people living with or at risk of HIV, and a future for young people free from AIDS. We meet people and communities where they are to prevent new infections and ensure access to care, treatment, and support.

Since its founding in 1992, the Foundation has pursued its vision of an AIDS-free future for everyone, emerging globally as one of the foremost organizations fighting HIV and AIDS. Today, the opportunity to end AIDS amongst specific populations and geographical areas is achievable and will require working together to eliminate social, economic, and health disparities while ensuring equity and inclusion for all.

BACKGROUND: UK PrEP

We can see a future with no new cases of HIV in the UK. Together with our partners, we are increasing HIV testing, expanding access to pre-exposure prophylaxis (PrEP), and helping people stay on treatment. These collaborative efforts are vital in reaching this historic goal.

There are an estimated 113,500 people living with HIV in the UK, including around 4,700 people who are undiagnosed. HIV diagnoses are rising sharply among heterosexual men and women, particularly within marginalized communities and we are seeing a troubling trend in the number of people who have been lost to care and stopped treatment. PrEP, a safe, effective pill that can stop people acquiring HIV, has been available free of charge from NHS sexual health clinics since 2020, yet there isn’t equal access to this life-saving medication. These issues must be addressed if we are to end new cases of HIV in the UK.

Together with our partners ViiV Healthcare, Gilead Sciences, and Fast-Track Cities, we are working on two pilots to make PrEP more available in England. This will ensure that everyone at risk of getting HIV can easily access this vital prevention method, helping to reduce new HIV cases and protect vulnerable communities. The two pilots will focus on reaching groups that have to date been underserved by existing PrEP models, including women and Black African communities.

Over 18 months, the two PrEP innovation pilots will seek to demonstrate increased awareness and uptake amongst communities at high risk of acquiring HIV through equitable, cost-effective approaches.

One pilot will run across three sites (Brighton and Hove, Liverpool, and West Sussex) and focus on incorporating PrEP into existing NHS services, such as women's health hubs, antenatal appointments, cervical screenings, and community organizations supporting vulnerable people, to reach underserved communities where and when they are already engaging with the health system.

The second pilot will focus on introducing a digital direct-to-consumer PrEP offering paired with targeted grassroots engagement for residents of North East London’s Local Authorities (Barking and Dagenham, City of London, Hackney, Havering, Newham, Redbridge, Tower Hamlets, and Waltham Forest) to relieve pressure on sexual health clinics and attract new users.

Both pilots will be championed by Local Authorities and integrated into the existing NHS architecture, thus facilitating the development of a sustainable blueprint for PrEP services that is scalable and transferable across the UK.

Both grants will be assessed individually by their respective implementing organizations. Their assessment may address (or be aligned with) some of the evaluation objectives and questions below. Thus, the evaluator is expected to use their assessments/evaluations individually to construct a joint assessment of both grants, extracting insight at a general level by using both primary and secondary data collection.

The Elton John AIDS Foundation will share the evaluation plan that both implementing partners will follow individually with the selected consultant/evaluation agency to develop further the evaluation proposal for the joint assessment. Since this evaluation will cover two grants with different approaches, one important lens for this evaluation is to incorporate a comparative approach between the two pilots.

EVALUATION OBJECTIVES

The evaluation approach seeks to assess both grants together to extract joint learnings, aiming to pursue the following objectives:

• Assess delivery models

Evaluate the technical infrastructure, implementation strategies, and governance structures that enabled or hindered PrEP delivery across pilot sites.

Measure outcomes and effectiveness

Determine which interventions successfully reached key populations, improved access, and enhanced quality of care.

• Evaluate sustainability

Identify factors that support long-term delivery and integration of PrEP services into routine health systems.

• Analyze value for money

Assess cost-efficiency, cost-effectiveness, and equity of the interventions, and explore potential for scale-up and future savings.

In pursuing these objectives, the insights generated will be disseminated to inform government officials and relevant departments, aiming for these solutions to be leveraged and/or integrated. The dissemination of insights will be led by the Elton John AIDS Foundation and the implementing organizations.

EVALUATION QUESTIONS

1. Technical / infrastructure

a. Compare and contrast both pilot projects

b. What strategies or interventions were successful / unsuccessful in increasing the uptake of PrEP?

c. What leadership roles and governance structures were in place in the pilot areas. Were any roles or structures crucial in facilitating delivery of the interventions?

d. Are there common structural factors across both pilots that contributed to success? (e.g. strong clinical leadership, commissioner engagement, competency training)

e. What contextual factors may have influenced the outcomes? Were there environmental, cultural, or organizational factors that varied? How might these contextual factors limit generalizability?

2. Outcomes of the interventions

a. How well did the interventions target the people who needed it? What works for the different communities? How effective are the major clients’ journies through both pilots? (Where do users drop out by age, ethnicity, migration status, and housing stability?)

b. What can be said about the volume and trend of the services provided?

c. What is the PrEP-to-need ratio for each key population in each pilot area at baseline and pilot end, and how does it compare to the national benchmark?

d. Are the solutions facilitating access to key populations (lowering thresholds)?

e. By bringing the learning together from both pilots, do we gain a deeper understanding of how to deliver PrEP services. Is there a greater magnitude in pooling the data?

f. Are there core components of any PrEP services that are needed for success?

g. What is the initiation (first prescription issued), persistence (repeat prescription from pharmacy/CVS data), and protection (TFV-DP drug levels in a purposive sub-sample) over time?

h. How do PrEP outcomes compare to counterfactual scenarios (e.g. HIV incidence without the previous models) in key population?

i. Are PrEP services integrated with other health services (e.g., STI testing, contraception, harm-reduction) for greater impact?

3. Sustainability

a. What key success factors drive sustainability? What are the relationships in play?

b. What evidence is required to demonstrate ongoing investment? How do interventions become business as usual?

c. Are local health systems, supply chains, and providers being strengthened or overloaded by these models?

d. How do current commissioning arrangements influence the sustainability and scale-up potential (including Integrated Care Boards and Local Authorities)?

e. To what extent did the Foundation funding catalyze innovation that the NHS system would not otherwise have prioritized?

f. Is the program adaptable to changes in HIV epidemiology or drug technology (e.g., switch to CAB-LA)?

4. Value for Money (VfM)

a. Efficiency

i. What is the cost per person initiated and continuing on PrEP? What is the cost per additional person reached, initiated, or retained as the program expands?

ii. Does the pilot deliver additional PrEP uptake, retention, or reach at an acceptable additional cost compared to existing services (ICER)?

iii. Is there task-shifting to nurses, peer educators, or community health workers that reduce operation costs as a result of efficiencies brought by both pilots?

iv. Suggested analysis:

1. Marginal cost curve: plot cost per PrEP client as volume increases

2. Budget impact analysis: what is the cost of targeting key population at scale?

b. Equity

i. What proportion of resources and services are reaching key populations (GBMSM, cisgender women, trans women, non-GBMSM men, sex workers, migrants, Black, Asian and minoritized ethnic groups, and people who inject drugs)? What major elements within the pilots drive efficiency the most considering the end target populations?

ii. Do pilots help addressing regional disparities?

iii. How comparable is the cost of reaching key populations vs general population?

c. Sustainability

i. Are the models cost-saving innovations?

ii. What is the affordable cost to scale these pilots?

PROPOSED EVALUATION METHODOLOGY

The evaluation will adopt a mixed-methods, comparative case study approach, drawing primarily on secondary data (including monitoring data and completed evaluations for each pilot which both includes VfM analysis), complemented by targeted qualitative data collection (e.g. stakeholder interviews) and additional quantitative analysis where required, particularly for the Value for Money (VfM) component. The two pilots will be analyzed comparatively to identify transferable lessons.

A theory-informed approach will be used to assess how interventions contributed to observed outcomes, supported by triangulation of quantitative data, qualitative insights, and program documentation.

Quantitative analysis will focus on PrEP uptake, retention, and equity using routine data. The VfM component will include analysis of cost-per-outcome, incremental cost-effectiveness (where feasible), budget impact and cost-saving analysis drawing on and synthesising existing VfM analyses from each pilot.

Where necessary, additional analysis will be undertaken to harmonize and strengthen comparability across pilots. This may include developing a cross-walk to align key cost and outcome metrics across pilots, and undertaking additional analysis where needed to ensure comparability and completeness. VfM analysis should align, where appropriate, with UK best practice guidance.

The evaluator is encouraged to apply an implementation science framework (e.g. RE-AIM or similar) to assess reach, effectiveness, adoption, implementation, and maintenance of the interventions. Where appropriate, qualitative analysis may draw on structured frameworks (e.g. CFIR) to systematically assess barriers and facilitators to implementation.

Qualitative data will provide insights on implementation, governance, and sustainability. The evaluation will generate policy-relevant, actionable findings to support advocacy and scale-up decisions. The evaluation outputs should be fit for purpose for dissemination to key stakeholders, including NHS England (NHSE), UK Health Security Agency (UKHSA), Integrated Care Boards (ICBs) and Local Authorities (LAs) in the pilot sites, the Department of Health and Social Care (DHSC), BASHH, BHIVA, and the APPG on HIV. The evaluator is expected to produce tailored outputs for these audiences (e.g. commissioning briefs, implementation guidance, and policy briefs).

DELIVERABLES

● Inception report

● Data collection tools

IRB submission (Evaluator must follow UK HRA guidance, UK GDPR, and NHS data governance requirements)

● Data analysis

● Draft evaluation report

● Final evaluation report

EXPERIENCE

• Public health evaluation experience, ideally in HIV prevention, PrEP, or sexual health programs

Strong mixed-methods expertise

Experience with complex / multi-site program evaluations, including comparative analysis across different models

• Demonstrated expertise in health economics / Value for Money analysis

Experience working with routine health data systems (e.g. NHS datasets, service delivery data, digital health platforms)

Understanding of health systems and service delivery in the UK (NHS context strongly preferred)

• Ability to assess scalability and sustainability of health interventions

Experience engaging multiple stakeholders (e.g. commissioners, providers, community organisations)

• Strong analytical and synthesis skills

BIDDING PROCESS

Applicants should submit a full technical proposal of no more than eight pages (excluding timeline, Annexes, and Appendices) in English along with a detailed financial proposal in USD. The following are the minimum requirements that should be included in the application:

Overall approach and methodology

Ethical considerations and risk management

Evaluation team and delineation of responsibilities

• Financial proposal in USD (Annex or Appendix)

• Timeline (Annex)

• CVs of external team (Annex)

• Declaration of Conflict of Interest, with mitigation strategy if applicable (Annex)

One sample report of a previous similar work (Appendix)

There is no set template for the technical proposal; however, we do not require a background section. Instead, it should begin with your proposed approach for addressing the objectives and evaluation questions. The financial proposal should reflect a realistic and cost-efficient budget that enables delivery of a high-quality evaluation whilst demonstrating value for money. Applicants should ensure that the proposed costs are aligned with the methodology, level of effort, scope, risks, and geographic spread of the assignment. A succinct narrative must be included in the budget table to explain assumptions behind each line.

Applicants should be prepared to work within NHS data governance requirements, including the use of Data Sharing Agreements (DSAs). Bidders should account for typical NHS datasharing timelines within their proposed approach and timeline.

The Declaration of Conflict of Interest must explicitly address independence from pilot implementing organizations, in addition to standard financial or institutional conflicts, and outline any proposed mitigation strategies.

Applicants are encouraged to articulate their approach to assessing scalability and replicability of interventions, including reference to established frameworks where appropriate.

The project budget shall not exceed USD 40,000.

TIMELINES

• Proposal submission: Before 14th May 2026

Supplier appointed: 22nd May 2026

Inception meeting: 26th May 2026

Final Inception report submission: 1st June 2026

Draft evaluation report submission: 28th Feb 2027

Final evaluation report submission: 30th March 2027

SUBMISSION

Please submit your application by 14th May 2026, 23:59 GMT using “Application: UK PrEP Grand Evaluation” as the subject line to luis.espinal@eltonjohnaidsfoundation.org and vikki.pearce@eltonjohnaidsfoundation.org. Applicants are responsible for all costs associated with preparing their proposal. All enquiries will be treated confidentially.

QUALITY ASSURANCE

The Foundation reserves the right to request revisions of deliverables if they do not meet the Foundation’s standards. Performance of the consultant(s) will be assessed on timeliness, quality of work, ethical conduct, and responsiveness to the Foundation.