This is a new activity to support a technical advisor to the Ministry of Health & Social Services (MoHSS) for roll-out of HIV-related palliative care services, including support for the national Integrated Management of Adult Illnesses (IMAI) palliative care program. This activity relates to other Basic Care services: MoHSS (7331), Intrahealth (7404), Potentia (7340), & I-TECH (7349), PACT/APCA (#8043) & PACT grantee links (#7412), DAPP (#7326), RPM/SCMS (#7967) as well as to MoHSS ARV services (#7330), Potentia ARV services (#7339), & CDC systems strengthening (#7360).

Palliative care technical expertise in Namibia is currently limited to two oncologists & a few cancer nurses in the Government Cancer hospital. Hospices found throughout many parts of Southern Africa, which are largely focused on end of life care (especially prior to ART) & often provide broader technical support to PEPFAR investments to advance comprehensive HIV-related palliative care do not exist in Namibia; this has greatly limited the development & expansion of HIV-related palliative care. In FY06, the USG & its partners, including the MoHSS, began receiving technical assistance from the African Palliative Care Association (APCA) & the USAID Regional Technical Advisor for HIV/AIDS Palliative Care which will continue in 2007. While significant program accomplishments are underway with this technical support, there exists a critical need to have an in-country, experienced, full-time palliative care technical advisor who is dedicated to development, decentralization, monitoring & evaluation of HIV-related palliative care in Namibia. This advisor will directly support the MoHSS development of palliative care at facility levels, including support for implementation & monitoring of the WHO Integrated Management of Adult Illness (IMAI) program which is pending final approval by the MoHSS. The advisor will also support MoHSS goals to advance pediatric care through its training program & the MoHSS Integrated Management of Childhood Illness (IMCI) program. This advisor will further support the current MoHSS Coordinator for Palliative Care & OI Services in the MoHSS Directorate of Special Programs to develop the Coordinator's palliative care expertise & leadership in palliative care. The technical advisor will also serve as a liaison between the MoHSS case management unit's implementation efforts, the extensive ITECH trainings & mentorship programs, & the IMAI site nurses & their referring district ART doctors. The technical advisor will also closely collaborate with the MoHSS Family Health Division who is responsible for community-based palliative care, clinical nutrition & FP/HIV integration, USG partners (ITECH PC:BHCS_7349, PACT PC:BHCS_7412, DAPP PC:BHCS_7326 & RPM+/SCMS PC:BHCS_7967) to address other critical program gaps in the Government which are essential to palliative care. This includes partnering with the MoHSS nutrition subdivision & ITECH nutrition advisor to ensure that developments in clinical nutrition are well integrated into HIV/AIDS palliative care programs; partnering with the MoHSS Family Health Division in Primary Health Care Services Directorate & the Global Fund to strengthen the delivery community-home based care & the integration of palliative care at home & community levels; & partnering with the family planning unit & ITECH to ensure that MoHSS investments in family planning begin to integrate with HIV/AIDS service delivery areas. Lastly, although the emphasis of this advisor will be palliative care, the technical advisor will also support the goals of ARV services. The advisor will coordinate closely with SCMS/RPM+ to address gaps in procurement & supply chain management for home based care kits & essential palliative care medications (SCMS/RPM+ PC:BHCS_7967 & SCMS/RPM+ ARVDrugs_7449).

The technical advisor will emphasize key palliative care priorities across program areas will include the provision of the preventive care package for adults & children which includes cotrimoxizole prophylaxis for Stage III, IV disease or CD4<300 and for HIV-exposed/infected children; TB screening & isoniazid preventive therapy in select sites; integrated CT; child survival interventions for HIV-positive children such as infant young child feeding during weaning, growth monitoring & immunizations; clinical nutrition counseling, anthropometric measurement, monitoring, referral, micronutrient supplementation & minimal targeted nutrition supplementation for severely malnourished PLWHA who are on ART; prevention strategies which include balanced ABC prevention messaging, condoms, support for disclosure of status, referral for family planning & PMTCT services, reduction in alcohol use & gender-based violence including assistance as needed through government centers for abused women & children. Key palliative care priorities also include other OI management, ART adherence, routine clinical monitoring & systematic pain & symptom management. Closer partnerships with districts & communities will allow increased opportunities to expand safe water & hygiene strategies & access to malaria prevention for PLWHA & their families, including leveraged support

from Global Fund-supported for bed nets. The advisor will also work with the Ministry of Agriculture & Rural Development & other partners to explore the feasibility & cost of appropriate safe water strategies for PLWHA. It is also anticipated that roll-out of IMAI will likely result in MOHSS development of a national palliative care policy that allows nurses to prescribe narcotics & symptom-relieving medications. Technical support from APCA (#8043) will support this activity.

The technical advisor will ensure gender-sensitive approaches, including equitable training & support of male & female health care workers with the goal of equitable access to HIV/AIDS services for PWLWHA & their families throughout USG-supported programs.

This activity will provide funding for one laboratory scientist and one TB /Quality Assurance specialist to be placed at the Namibia Institute of Pathology (NIP) for the purposes of strengthening HIV diagnosis in young infants, introducing HIV incidence testing into routine antenatal surveillance, to continue surveillance for HIV drug-resistance, improve TB diagnosis and strengthen Quality Assurance. It relates to the MoHSS/PMTCT Activity #7334, CDC #7357 and NIP #7927 and TBD #7358.

In FY05, CTS hired and placed a laboratory scientist at NIP as a technical advisor to help develop and implement standard operating procedures to ensure quality services related to diagnostic DNA PCR, CD4, HIV incidence testing, and resistance testing. During FY05, the diagnostic algorithm for pediatric diagnosis using PCR has been developed and the use of dried blood spots (DBS) has been field-tested. During FY06 in collaboration with the Ministry of Health and Social Services (MoHSS) PMTCT program, the diagnostic DNA PCR has been introduced for symptomatic infants and HIV-exposed infants at 6 weeks of age. Staff at the lab have been newly trained in PCR, new equipment has been bought and health workers have been trained in the collection of dried blood spots. Also, following training in the BED incidence assay by CDC/HHS in October 2005, NIP plans to introduce HIV incidence testing with banked specimens of the 2006 sentinel survey once an updated assay is available. The first threshold survey of HIV drug-sensitivity is to be conducted in late 2006 on samples from the 2006 sentinel survey. During FY06 in collaboration with the Association of Public Health Laboratories, 2 laboratory management training workshops have been conducted. In FY07, there will be a follow up and evaluation of the management training with an emphasis on Strategic planning. In FY06, this scientist has also taken on an key role as laboratory liaison for USG laboratory related activities.

In FY06, a team of TB laboratory experts from CDC traveled to Namibia to assess the Lab services provided by NIP TB Labs. An action plan based on the laboratory assessment was implemented to address problems identified through targeted technical assistance, training, logistical and information technology support, and quality assurance. A team of Tb experts from the American Society of Microbiology and a Russian scientist spent 2 months to help strengthen the TB lab. One TB/QA laboratory specialist will be hired and placed at the Namibia Institute of Pathology to work with the USG supported laboratory scientist to implement the recommendations made and to support the overall NIP quality assurance system.

This activity also leverages resources with the Global Fund, the Bristol Meyers Squibb "Secure the Future" project in the Caprivi, who provide funding for PCR tests, and the MOHSS which provides financial support to the NIP to perform diagnostic PCR testing and other HIV-related laboratory services.

This activity continues USG FY04/FY05/FY06 funding to CTS Global and relates to these other SI activities: the Ministry of Health and Human Services (MOHSS) (7332), Potentia (7338), National Institute of Pathology (NIP) (7995), I-TECH (7355), and CDC (7359).

The emphasis for this activity will be to continue and expand the support from 2 technical advisors to Namibia's National AIDS Program, one to monitoring and evaluation (M+E) activities and one to the National Health Information Systems (HIS) Unit.

Monitoring and evaluation is a critical element of the National response to HIV/AIDS, the third ‘one' (along with one unified strategic plan and one country coordinating body) in the UN framework. Namibia is finalizing an M+E plan to measure progress toward the goals in its national strategic plan for HIV/AIDS. This M+E plan stipulates indicators required from all government and non-government sectors; however, human capacity to finalize this plan and to obtain and process the indicators is extremely limited. To address this gap, the USG seconded technical advisors (TAs) to the National AIDS/TB Program, first a health information systems (HIS) advisor in FY05 and then an M+E specialist in FY06. To develop and sustain local capacity, these technical advisors work closely with their counterparts in the MoHSS.

Since FY05, the USG TA for HIS has supported establishment of the current national management information system (MIS) for ART and PMTCT while strengthening the MIS for VCT and TB. These systems have been providing crucial information for reports for MoHSS and partners (including PEPFAR) as well as assisting the government in projecting future program needs. However they are ‘stand-alone' systems: data in a given department (clinic, laboratory, pharmacy) resides on one computer and cannot be easily accessed by the other departments; hence resulting in entry of the same information in more than one place. Moreover, facilities cannot share computerized data with each other unless cumbersome data management is performed.

In FY07 the HIS TA will focus on migrating data to a new system (web-hosted or networked) that will allow rapid exchange of information to the national level and among facilities to improve patient tracing (and hence avoid default), facilitate reporting, and promote data use for policy/program decisions. This phase will leverage information technology resources from the USA through private-public partnerships developed by OGAC and a partnership between the MoHSS and local information technology expertise (both public and private). Also in FY07, this TA will continue to: facilitate training of sub-national and national level data managers to expedite reporting and data synthesis, improve data quality, strengthen local use of information and dissemination; and continue to support the design and analysis of national surveys, including those for HIV drug resistance, HIV incidence, longitudinal surveillance of training (L-STEP), and TB drug resistance. To facilitate maximum data use, this TA will also continue to support spreadsheet modeling to inform policy makers of the current and future extent of the epidemic so that sufficient Government and partner support can be secured. Finally, this TA will continue from FY05/FY06 as instructor for the epidemiology/ biostatistics module of the University of Namibia MPH program to build local capacity in epidemiological study design and data collection/analysis.

The USG M+E TA has assisted in formulating/executing the M+E plan and designing and executing national surveys in the plan, including the HIV sentinel survey in pregnant women and the demographic and health survey (DHS). During FY07, this TA will continue support of national surveys, including analyzing 2006 sentinel survey results, coordinating the Health Facility Survey and the Demographic & Health Survey (DHS), and planning a BSS+ survey focused on HIV/AIDS to be implemented in FY2008. To promote appropriate execution and interpretation of these surveys, this TA will coordinate training workshops emphasizing surveillance concepts and general M+E concepts to all national and sub-national M+E personnel. The TA will also provide support for implementing the Ministry's computer-based management information system designed to track the indicators in the M+E plan (MTP3). This TA will also support M+E dissemination activities including quarterly reports required by MoHSS, biannual PEPFAR, Global Fund and UN reporting requirements. The M+E TA will also coordinate with the HIS TA to support the migration of HIS.

Leveraging the foundation of information systems and data capture personnel established

between FY04-FY06, SI objectives in FY07 will concentrate heavily on data quality and data use for program and policy improvement, since the lack of a fundamental M+E framework of systems that define and collect basic indicators forced FY05/FY06 activities to focus on basic building blocks of M+E. The HIS TA, while continuing support to routine data collection and indicator calculation, will focus efforts on using existing databases to report more detailed indicators (including TB/HIV and ARV drug adherence), both to support L-STEP and targeted evaluations as prioritized by the MoHSS, and to improve data quality through the HIVQUAL initiative. FY07 will, for the first time, include funding to support MoHSS personnel studying for their MPH degree at the University of Namibia to complete data analysis, interpretation, and presentation in their MoHSS program area with mentoring from the HIS technical advisor/epidemiologist. With existing data, the M+E TA will move on from coordinating the National M+E Plan and implementing surveys to create reports that synthesize information into practical recommendations for improving prevention, care, and other efforts to mitigate the epidemic.

This activity leverages resources with: the Global Fund to support the Health Facility Survey and DHS; the European Commission to support the national M&E MIS; and WHO to support Namibia's participation in the Health Metrics Network.