This activity is a continuation of FY06 direct funding to the Ministry of Health and Social Services (MoHSS) and relates to other activities in PMTCT, including Namibia Institute of Pathology's (NIP) provision of a technician for PCR (7927), Potentia's provision of trainers through I-TECH (7344), training costs covered by I-TECH (7354), CDC's activity to provide nurse supervisors and supervisory visits (7357), faith-based Intrahealth (7403), and the System Strengthening activity by CDC (7360).

In support of PMTCT services, the Ministry of Health and Social Services (MoHSS) is responsible for national coordination, resource mobilization, monitoring and evaluation, training, and policy development. The USG will continue to support MoHSS in FY07 and build on FY06 activities through:

(1) Support to print ANC and maternity registers, purchase rapid test kits, clinic equipment (scales, hemoglobinometers, lockable cabinets for ARV drugs), a vehicle for the national program, and ARV drugs for PMTCT. The national Technical Advisory Committee has made recommendations to strengthen the PMTCT regimen to include a short-course of AZT beginning at 28 weeks gestation, plus a 7-day regimen of AZT/3TC to the mother and baby postpartum, in addition to single-dose nevirapine. It is anticipated that, once approved, this will be rolled out at the 34 public hospitals initially before reaching the health center and clinic level. The USG will support the costs of these ARV drugs to reach 50% of the eligible population.

(2) Support for up to 500 Community Counselors (CC) who work in health facilities. MOHSS established the CC cadre in 2004 to assist doctors and nurses with provision of HIV prevention, care, and treatment services, including HIV counseling and testing, PMTCT, ART, TB, and STI; and to link and refer patients from health care delivery sites to community HIV/AIDS services. Community Counselors, who perform rapid HIV testing, play a major role in PMTCT services as the primary provider of counseling and testing (CT) in ANC in support of the nurse. Recruitment of HIV positive individuals as CC is a strategy employed to reduce stigma and discrimination. To date, 175 CC (~25% of whom are HIV positive) have been placed at 74 health facilities. With FY07 support, this number will increase to 430 by September 2007, and to a final target of 480 by December 2007. PEPFAR funding for the "Community Counselor Package" includes: recruitment and salaries for the CC, 13 regional coordinators, and an assistant national coordinator (implemented through the Namibian Red Cross); initial and refresher training for CC (implemented by a local training partner); supervisory visits by MoHSS staff who directly supervise CC; training for MoHSS accountants who provide financial management assistance to the program; support for planning meetings and an annual retreat for CC; and support for CC participation at international conferences. Within COP07, funding for CC who dedicate part of their time to this activity, is distributed among six MoHSS program areas: Preventing Mother to Child Transmission (7334), Abstinence and Be Faithful (7329), Other Prevention (7333), HIV/TB (7972), Counseling and Testing (7336), and ARV Services (7330). This activity also links with CDC's system strengthening activity (7360).

(3) Covering the costs of diagnostic PCR testing. In FY07 the MoHSS will receive direct funding to pay the NIP for tests performed on infants of HIV+ mothers, inclusive of mission health facilities. This relates to projects within MoHSS ARV services (7330). With USG support, the standard for the diagnosis of HIV infection in children <18 months of age was improved in FY06 to include a diagnostic PCR test on a dried blood spot specimen. The introduction of rapid testing performed by community counselors in FY06 along with an opt-out HIV testing strategy and linkages to ART has contributed to a large proportion of women who now know their HIV status. A USG-hired laboratory scientist (NIP_ Lab Support_7337) is supporting the NIP to respond to the clinical demand for diagnostic PCR and improve the standard operating procedures of the lab to ensure quality services.

The NIP is a parastatal organization and charges a fee to the MoHSS for all laboratory tests. In FY07, the USG will provide funds to the MoHSS to pay the NIP charges for performing at least 8,000 diagnostic PCR tests on infants of HIV+ mothers now that capacity is further developed. This nationwide target will be reached by working through PMTCT sites and ART clinics to train health care workers on PMTCT, pediatric diagnosis and care, the collection of DBS specimens, and the development of a national PCR health

information system. This activity leverages resources with those of the private sector and Global Fund.

(4) Training for an additional 80 Traditional Birth Attendants (TBA) on their role in PMTCT services, including promotion of HIV prevention, reproductive health services for HIV-positive women, and referral of pregnant HIV-positive in the northern regions will be continued as approximately 25% of deliveries occur outside of a health facility.

(5) A nationwide educational campaign by the Directorate of Primary Health Care to promote PMTCT services in collaboration with the Ministry of Information and Broadcasting (MIB). Funding will be provided to develop, produce, and disseminate new PMTCT educational materials for strategic communications in the clinical setting, including the promotion of male involvement.

This activity will support procurement of HIV Test Kits and Supplies. With PEPFAR support, MoHSS will continue to purchase an increasing volume of Determine and Unigold test kits (using a parallel testing algorithm) to be used at MoHSS and mission-managed sites for HIV testing of a projected pregnant women, using SureCheck as a tie-breaker in rare instances of discordance; HIV rapid test starter packs to launch new testing sites; and rapid HIV test training supplies for training community counselors. Test kits and supplies are procured and distributed to health facilities by the Central Medical Stores through existing mechanisms. The volume of test kits needed continues to increase as more sites and community counselors are certified to perform rapid testing.

This activity is an expansion over FY06 and includes continued training and deployment of Community Counselors support for education on the association between alcohol and HIV.

(1) MOHSS established the Community Counselor cadre in 2004 to assist doctors and nurses with provision of HIV prevention, care, and treatment services, including HIV counseling and testing, PMTCT, ART, TB, and STI; and to link and refer patients from health care delivery sites to community HIV/AIDS services. Emphasis is placed on the recruitment of HIV positive individuals as community counselors as a strategy to reduce stigma and discrimination. To date, 175 community counselors (approximately 25% of whom are HIV positive) have been placed at 74 health facilities. With FY07 support, this number will increase to 430 by September 2007, and to a final target of 480 by December 2007. PEPFAR funding for the "Community Counselor package" includes: recruitment and salaries for the community counselors, 13 regional coordinators, and an assistant national coordinator (implemented through the Namibian Red Cross); initial and refresher training for community counselors (implemented by a local training partner); supervisory visits by MOHSS staff who directly supervise the community counselors; training for MOHSS accountants who provide financial management assistance to the program; support for planning meetings and an annual retreat for community counselors; and support for community counselor participation at international conferences. Within COP07, funding for Community Counselors, who dedicate part of their time to this activity, is distributed among six Ministry of Health and Social Services activities: Preventing Mother to Child Transmission (7334), Abstinence and Be Faithful (7329), Other Prevention (7333), HIV/TB (7972), Counseling and Testing (7336), and ARV Services (7330). This activity also links with CDC's system strengthening activity (7360).

Community Counselor prevention activities include delivery of AB and C messages appropriately targeted to various risk groups defined by age, sex, HIV status, and presentation of other STIs, and distribution of condoms to high-risk groups in health facilities. Community counselors are the primary personnel at health sites responsible for providing HIV testing and counseling, and in this capacity, are well-positioned to deliver AB prevention messages to those who test either positive or negative. They conduct both group and individual sessions primarily in a range of outpatient settings (antenatal clinic, TB clinic, ART clinic, outpatient services for VCT, etc). Community counselors are trained to encourage clients to bring in their partners for counseling and testing, providing opportunities to deliver prevention messages to discordant couples (approximately 12% of couples in VCT are discordant). As part of development of an individual risk reduction plan during the post-test counseling stage, the options of sexual abstinence, partner reduction, and being faithful to a partner of known HIV status, along with correct and consistent condom use, are presented as ways in which to prevent HIV.

A high proportion of community counselors' clients will be sexually active HIV-positive patients in health facilities, providing an opportunity for Prevention with Positives approach. Beginning in October 2006, community counselors will be among the first to trained to roll out the new in "Prevention with Positives" counseling (using the generic curriculum developed by CDC) and will provide these counseling services at the ART sites to which they are assigned. Community counselors will promote couples counseling and encourage all their clients, but particularly PLWHA, to reduce their high risk behaviors through abstinence, being faithful to one partner or promoting "secondary abstinence." Couples counseling and testing will also be reinforced to identify prevention opportunities through discordant couples. In addtion, funding for this activity includes travel for technical support for PwP from Atlanta.

(2) Together with partner NGOs, representatives from the Directorate of Social Services, MoHSS participated in the PEPFAR-supported meeting on HIV and alcohol in Tanzania in August 2005. Through collaboration with active NGOs/FBOs, support will be given to MOHSS, which chairs the National Drug Control Commission, to convene stakeholder meetings and develop materials to educate the public about the association between alcohol consumption, high-risk sexual behavior, and HIV infection.

The $75,000 plus up funds will support two components: (1) Design and implement a nationwide alcohol intervention. This intervention will be shaped in the latter half of FY2007 as a result of technical assistance that will develop a strategic plan for addressing the monumental issue of alcohol abuse as it relates to HIV transmission and ART

adherence. [$50,000] (2) Conduct the first national conference on "Men and HIV". This conference will be planned and carried out by the end of FY2007. Funding will support meeting space, travel for participants and speakers, and other related costs. Major objectives of the conference will be to bring together stakeholders from throughout Namibia to develop strategies to expand men's uptake of HIV prevention and care services. Key to this conference will be to gain extensive input from men to shape a strategic plan. Another component of the conference was to begin to have policy discussions around male circumcision. International experts will be invited to present findings from the recent MC studies, to review WHO guidance, and to begin to talk about the possibilities for MC efforts in Namibia. [$25,000]

This activity includes three primary components: (1) Continued training and deployment of Community Counselors (CC), (2) New activity for procurement of condoms for high-risk individuals, and (3) targeting STI Patients for HIV counseling and testing and correct and consistent condom use.

(1) Training and Deployment of Community Counselors (CC) ("Community Counselor initiative"). MOHSS established the CC cadre in 2004 to assist doctors and nurses in health care facilities with provision of HIV prevention, care, and treatment services, including HIV counseling and testing, PMTCT, ART, TB, and STI; and to link and refer patients from health care delivery sites to community HIV/AIDS services. Emphasis is placed on the recruitment of HIV positive individuals as CC as a strategy to reduce stigma and discrimination. To date, 175 community counselors (approximately 25% of whom are HIV positive) have been placed at 74 health facilities. With FY07 support, this number will increase to 430 by September 2007, and to a final target of 480 by December 2007. PEPFAR funding for the "Community Counselor package" includes: recruitment and salaries for the CC, 13 regional coordinators, and an assistant national coordinator (implemented through the Namibian Red Cross); CC initial and refresher training (implemented by a local training partner); supervisory visits by MOHSS staff who directly supervise the CC; training for MOHSS accountants who provide financial management assistance to the programme; support for CC planning meetings and an annual CC retreat; and support for CC participation at international conferences. Within COP07, funding for Community Counselors, who dedicate part of their time to this activity, is distributed among six program areas, all of them MOHSS activities: Preventing Mother to Child Transmission (7334), Abstinence and Be Faithful (7329), Other Prevention (7333), HIV/TB (7972), Counseling and Testing (7336), and ARV Services (7330). This activity also links with CDC's system strengthening activity (7360).

Community Counselor prevention activities include delivery of ABC messages appropriately targeted to various risk groups defined by age, sex, HIV status, and presentation of other STIs, and distribution of condoms to high risk groups. CC are the primary personnel at health sites responsible for providing HIV testing and counseling, and in this capacity, are well-positioned to deliver prevention messages to those who test both positive and negative. CC are trained to encourage clients to bring in their partners for counseling and testing (CT), providing opportunities to deliver prevention messages to discordant couples (approximately 12% of couples who are tested at VCT sites are discordant). Beginning in September 2006, CC will be trained in "Prevention with Positives" counseling (using CDC curriculum) and will provide these counseling services at the ART sites to which they are assigned.

(2) Procurement of Condoms. This new activity is being added to leverage support with the Global Fund, which will provide $609,000 for the Ministry's new "Smile" brand of male condoms and $338,000 for the female condom in 2007. The "Smile" condom is comparable in quality to local commercial and socially-marketed condoms and was launched by the Ministry in 2005 following complaints from the public that the free condoms distributed from health facilities were substandard. The public response to the "Smile" condom has since been overwhelming and demand has exceeded the Ministry's ability to purchase the amount needed. These condoms are manufactured in Malaysia and undergo quality assurance in a local laboratory when delivered in Namibia prior to distribution to improve ability to meet demand. Commodity Exchange is a local company which has been contracted by the Ministry to establish a condom production factory and quality assurance laboratory with funding from the Global Fund. A 2005 USG-funded evaluation of condom supply and logistics evaluation concluded that the quality assurance laboratory and plans for local production needed supplemental support. The Ministry requests an additional $100,000 to meet a projected financial gap to purchase an additional 2,000,000 "Smile" condoms in 2007. These condoms will be distributed free of charge to health facilities for use by high-risk clients (HIV-positive patients, STI patients, TB patients, and patients having sex with a person of unknown HIV status) and for further distribution to NGO/FBO partners for distribution to high-risk individuals (mobile workers, commercial sex workers, PLWHA and their partners, and persons having sex with a partner of unknown HIV status).

(3) STIs.This new activity will include printing of new STI prevention and treatment guidelines developed with USG-supported TA to include routine CT for STI patients,

partner notification and testing, and clinical management of HIV-positive patients with STIs. It also includes funding for the Ministry personnel to travel to the regions and districts to supervise and support sites with implementation of the new guidelines.

In FY07 CDC will further provide technical assistance and capacity building to the MoHSS STI Program with the arrival of a public health advisor (PHA) as Deputy Director of Operations who has expertise in STI program management. Approximately 25% of this PHA's time will be dedicated to assisting the MoHSS STI Director as needed with activities, such as training, development of policies and procedures, and quality assurance that may enhance STI services and facilitate STI/HIV integration.

The $325,000 plus up funding supports three components: (1) USG support for procurement of condoms by the MOHSS. This activity will continue to leverage support with the Global Fund, which provides funding support for the Ministry's "Smile" brand of male condoms. The public response to the "Smile" condom has since been overwhelming and demand has exceeded the Ministry's ability to purchase the amount needed. These condoms are manufactured in Malaysia and undergo quality assurance in a local laboratory when delivered in Namibia prior to distribution to improve ability to meet demand. Commodity Exchange is a local company which has been contracted by the Ministry to establish a condom production factory and quality assurance laboratory with funding from the Global Fund. The additional funds will allow for the purchase of an additional 4,000,000 "Smile" condoms in 2007. These condoms will be available free of charge to ART clinic patients and will further support ongoing "prevention with positive" efforts in Namibia. [$250,000] (2) Design and begin to implement a nationwide alcohol intervention. This intervention will be shaped in the latter half of FY2007 as a result of technical assistance that will develop a strategic plan for addressing the monumental issue of alcohol abuse as it relates to HIV transmission and ART adherence. [$50,000] (3) Conduct the first national conference on "Men and HIV". This conference will be planned and carried out by the end of FY2007. Funding will support meeting space, travel for participants and speakers, and other related costs. Major objectives of the conference will be to bring together stakeholders from throughout Namibia to develop strategies to expand men's uptake of HIV prevention and care services. Key to this conference will be to gain extensive input from men to shape a strategic plan. Another component of the conference was to begin to have policy discussions around male circumcision. International experts will be invited to present findings from the recent MC studies, to review WHO guidance, and to begin to talk about the possibilities for MC efforts in Namibia. [$25,000]

This funding will support technical assistance to the Ministry and other key stakeholders to develop a strategic plan to address the impact of alcohol on HIV transmission and treatement adherence. Technical assistance will be provided by appropriate persons identified by CDC or OGAC. These persons will work in collaboration with key persons in-country to coordinate a retreat or other such gathering of key officials to inventory existing efforts, develop a strategic plan, and to begin to plan an alcohol intervention that will ultimately be carried out by the Ministry of Health and Social Services and other appropriate Ministries within the Government of the Republic of Namibia. Funding will support travel costs for the TAs, meeting space, and material costs.

This activity continues from FY06 & relates to the Ministry of Health & Human Services (MoHSS) activity for ART services (#7330), as well as to I-TECH Basic Care (ITECH PC:BHCS_7349), APCA activity (PACT PC:BHCS_8043), SCMS/RPM+ activity (SCMS/RPM+ PC:BCHS_7967), Potentia's Basic Care & ART (#7340 & # 7339), Comforce (Comforce PC:BHCS_8024), CDC System Strengthening (CDC PASS_7360). This activity includes support to the MoHSS for gaps in equipment, supplies & lack of transport for established Communicable Disease Clinics (CDCs) & the 13 health centers & clinics that will begin decentralized rollout of ART & palliative care services.

The MoHSS is responsible for national coordination, resource mobilization, monitoring & evaluation, training, & policy development in support of all HIV/AIDS related services. The MoHSS manages a network of more than 300 health facilities spread out over a vast geographic area in 13 health regions & 34 health districts. MoHSS leadership & implementation for facility-based palliative care for adult PLHWA is within the framework of WHO's Integrated Management of Adult Illness (IMAI) program. Adaptation of all 5 IMAI modules is underway & pending final approval by the MoHSS. Shifting tasks from physicians, nurses will begin providing palliative care & managing clients who are not yet eligible for ART & clients who have received their first 6 months of ART at hospital CDCs. Anticipated in 2007, the 13 regions will be responsible for the rollout of IMAI to selected health centers & clinics in their catchment area. The IMAI framework for decentralized HIV/AIDS training, service delivery standards, & task-shifting to district & community levels of care will inform the MoHSS decentralization plans & enable the health system to more adequately provide comprehensive HIV/AIDS care for Namibian communities. Technical advancement for pediatric care is provided by the MoHSS pediatric care & treatment training program & the MoHSS Integrated Management of Childhood Illness (IMCI) program.

Key priorities in facility-based palliative care service delivery will include the provision of the preventive care package for adults & children. This 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 immunizations and food supplements for weaning from breast-feeding; 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. Additional 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 USG will also work with the Ministry of Agriculture & Rural Development 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 (PACT PC:BHCS_8043) will support this activity.

Recent planning for palliative care rollout revealed a number of program gaps that the MoHSS is unable to support. Many of the targeted districts are ill-equipped in terms of equipment & supplies & lack of transport for established CDCs & the 13 health centers & clinics that will begin delivery of ART & palliative care services. Specifically, this activity includes 3 primary components:

(1) Procurement of equipment necessary to provide essential HIV-related clinical care, including tools to improve clinical monitoring such as simple portable lactate & hemoglobin meters, thermometers, ENT scopes, & weight/height scales for adults, children & infants (to enable appropriate anthropometric nutritional assessment, monitoring & referral). In an effort to address barriers to proper care of HIV-infected women, equipment will also be procured to improve gynecological screening & care of HIV-positive women to more adequately address HIV-related conditions such as cervical dysplasia & reproductive tract infections.

(2) Procurement of equipment & supplies for decentralized sites which will enable improved monitoring & supervision to facilities within the catchment area of the district hospital who will be implementing IMAI rollout. This includes office supplies & tools essential for IMAI palliative care rollout, including printing of IMAI patient cards & files.

(3) Procurement of additional vehicles to address significant transportation barriers in rural Namibia. With the addition PEPFAR support for 11 vehicles throughout Namibia & leveraged support with the Global Fund, it is anticipated that the MoHSS & PEPFAR partners will be able to provide improved support & supervision to facilities within the catchment area of the district hospital who will be implementing IMAI rollout. This includes support to the MoHSS to trace ART defaulters & strengthen outreach services which support the continuum of decentralized care between facilities & communities. This activity is coordinated & leveraged with the Global Fund, which is also supporting vehicle procurement, so that by 2007, all but two districts will have at least one vehicle to support HIV/AIDS care.

The program 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+ ARV Drugs_7449). Funding for this activity has been split between two activities: MOHSS Basic Health Care (#7331) (1/3 of the budget) & MOHSS ARV Services (#7330) (2/3 of budget). Activities 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 MoHSS programs.

Within COP07, funding for Community Counselors, who dedicate part of their time to this activity, is distributed among six program areas, all of them Ministry of Health and Social Services activities: Preventing Mother to Child Transmission (7334), Abstinence and Be Faithful (7329), Other Prevention (7333), HIV/TB (7972), Counseling and Testing (7336), and ARV Services (7330). This activity also links with CDC's system strengthening activity (7360).

This activity is a new extension of the Ministry of Health and Social Services' (MoHSS) Community Counselor initiative to support counseling and HIV testing of TB patients and relates to all provider-initiated counseling and testing services and VCT in health facilities. TB/HIV accounts for 10% of the overall cost of the community counselor initiative. According to the 2005 TB Electronic TB Register, only 16% of TB patients were tested for HIV. Anecdotally, this has increased significantly following new guidance that included Stage III disease (pulmonary TB) for ART eligibility, but capacity for CT of TB patients is limited.

Training and Deployment of Community Counselors. MOHSS established the Community Counselor cadre in 2004 to assist doctors and nurses in healthcare facilities with provision of HIV prevention, care, and treatment services, including HIV counseling and testing, PMTCT, ART, TB, and STI; and to link and refer patients from health care delivery sites to community HIV/AIDS services. Emphasis is placed on the recruitment of HIV positive individuals as community counselors as a strategy to reduce stigma and discrimination. To date, 175 community counselors (~25 % of whom are HIV positive) have been placed at 74 health facilities. With FY07 support, this number will increase to 430 by September 2007, and to a final target of 480 by December 2007. PEPFAR funding for the "Community Counselor package" includes: recruitment and salaries for the community counselors, 13 regional coordinators, and an assistant national coordinator (implemented through the Namibian Red Cross); initial and refresher training for community counselors (implemented by a TBD training partner); supervisory visits by MOHSS staff who directly supervise the community counselors; training for MOHSS accountants who provide financial management assistance to the programme; support for planning meetings and an annual retreat for community counselors; and support for community counselor participation at international conferences.

Supervised by a nurse, Community Counselors are the primary personnel at health sites responsible for providing HIV testing and counseling, providing pre-and post-test counseling and testing (using rapid tests) to TB patients.

The 2006 NTCP report indicates that 30% of TB patients were tested for HIV, out of which 67% were HIV positive. Majority of TB cases are HIV, justifying the need for TBHIV collaborative activities. The most crucial of the collaborative activities is to put in place a surveillance system which accurately captures patients with dual infection. Namibia is therefore introducing an electronic TB register developed by CDC in Botswana. This electronic register is being adopted by a number of SADC countries.

The funds requested will enable the Ministry of Health and Social Services to adapt the already prepared Electronic TB Register (ETR) for the Namibian National TB Control Programme (NTCP). The ETR is an Access-based tool that was originally developed in Botswana and has since been disseminated to South Africa and a number of other Southern African countries. This relatively large user group means that training and user support are accessible and the incorporation/modification of indicators is also facilitated. ETR will greatly improve upon the existing TB/HIV surveillance system which is paper based. This will accommodate more TB/HIV variables and provide required reports on TBHIV. The funding will enable the MOHSS to procure technical assistance for the adaptation and maintenance of the software, train 100 officers including District TB coordinators, data clerks, regional and national staff. The implementation will be piloted in Khomas region then rolled-out to all regions in Namibia. Prompt and efficient data processing is critical for effective patient management and program evaluation. Particularly with the emergence of XDR TB, it is essential that programme managers and policy makers have rapid access to data on treatment failure, drug sensitivity, and other indicators with demographic and regional disaggregation. Additional funds for the ETR have been leveraged from Global Fund and COP07 for purchasing of the computers and training nurses on computer skills. However, this funds

are not adequate, thus the need for extra funding. The ETR fits in COP07 plans which include recruiting and training community counselors who will be deployed in all TB clinics and wards. This is aimed at increasing the TB patients offered HIV testing and counseled on adherence to treatment for both HIV and TB.

This activity is linked to new plus up activities in HTXS as well as #7330 in HTXS in the original COP07 around the purchase of medical equipment. Specifically this funding will purchase infant weight scales with height monitors and lactate meters for Ministry of Health, FBO and MoD hospitals. This equipment will improve care provided in the clinics and will also decrease overall laboratory costs by avoiding the need to send out blood to the laboratory to test for lactate levels of patients on antiretroviral therapy. In addition to reducing laboratory costs, point of care testing for lactate levels will allow clinicians to receive and be able to respond to any abnormal results (the result of adverse reactions to ARVs) while the patient is still present in the clinic. This can significantly decrease morbidity and even mortality for some patients and also decreases the need for patients to return for these results, decreasing the burden of extra visits on the patient and the health center. The infant weight scales with height monitors also play a key role in the implementation of the new PEPFAR OGAC guidance around feeding of OVCs. This equipment will be integral in helping the health workers as well as care givers identify malnourished and under weight/height children, fecilitating access to food supplements and government grants for OVC.

Key Legislative Issues Wrap Arounds

Other

Table 3.3.09: Program Planning Overview Program Area: Counseling and Testing Budget Code: HVCT Program Area Code: 09 Total Planned Funding for Program Area: $ 8,435,009.00

Program Area Context:

USG support to counseling and testing (CT) is a high priority in Namibia, with the promotion of routine services in the clinical setting and VCT at non-governmental community centers. Routine services, confidentiality, and protection against discrimination and stigma are being integrated into the new national HIV/AIDS policy.

Since 2003, activities have included technical assistance to the MoHSS at the national level, development of national guidelines, training and curricula, establishment of rapid testing and QA, HIS support, renovations, and direct financial support for CT in health facilities, and community VCT centers. USG support in FY05 enabled the Namibia Institute of Pathology (NIP) to establish rapid testing quality assurance, training, and follow-up supportive services. Rapid testing was started for the first time in FY05 at 14 New Start VCT Centers and 6 health facilities. Rapid testing is now available in 55 large public health facilities (17% of all facilities). Rollout of rapid testing to all health facilities will be a major priority in FY07. The USG will continue to support training of health workers and NGO/FBO providers in CT, to supervise community counselors (CCs), and to introduce couples counseling in FY07. The Ministry will increase the number of CCs deployed to health facilities from 300 by early 07 to 500 by the end of 07.

As of FY06, the USG provides support to implement a network of 14 community-based community centers in 10 regions. The network began in 2003 with EU funding and 6 centers. Since FY04, USG funding expanded the network to 8 more centers, including establishing integrated CT within PMTCT and ART programs in 3 MoHSS supported mission hospitals. As a result of continued USG support for the extension and expansion of CT services, the network has seen dramatic increases in client numbers- the total number of CT clients rose from 13,425 in 2004 to 31,061 clients in 2005 to 48,000 in FY06. Average client flow grew to over 4,000 clients per month during FY06. Challenges encountered have been strong stigma particularly in some regions which have resulted in low uptake of testing services, significant gender imbalance resulting in low numbers of men accessing testing and up to 30% retesting rates at some centers. In 07 and in support of the goal of 65,000 new CT clients in community centers, USG community testing partners will implement focused community mobilization and a behavior change communication strategy focusing on first time testers, couples and increased male testing. It is hoped that 95% of those tested will be first time testers and that the number of couples tested will at least double from 8% to 16%.

The USG support for community centers is being leveraged by the Global Fund (GFATM) which is providing funding for the lead USG VCT partner to set up a community center at Eenhana, the 1st center in Ohangwena region. The MoHSS is expanding capacity within the public sector to increase CT provision with rapid testing through decentralization at health facilities principally financed by the USG and the GFATM. The GFATM has also provided an assistant CT coordinator in MoHSS to work with the USG-funded technical advisor. With DFID support, USG VCT partners have established 5 Tusano post-test clubs (PTC) in areas of high prevalence; Katima, Walvis Bay, Rundu, Katutura and Oshakati. With USG funding, focus groups will be conducted with PLWHA to determine what services would lead to a greater participation in post test clubs. A pilot activity will be initiated based on the formative research to meet the complex psychosocial support and palliative care needs of PLWHA. It will provide clients with comprehensive information referrals and counseling on a preventive care package as well as individual and group counseling sessions on treatment and care options, disclosure, and risk reduction strategies following the CDC "prevention with positives" model which will be adapted for community use in 07. A gendered approach to post-test service prevision will be ensured by undertaking a qualitative needs assessment to identify the support needs of men and women. Future strategies to meet the gendered needs and perspectives of post-test clients are likely to include strengthening linkages with men and women's support and advocacy groups, conducting gender-specific counseling sessions, engaging men as partners for PMTCT, and reaching men in non-traditional settings (e.g. sports clubs).

The introduction of community counselors into health facilities in mid-2005 has been a major boost to

provider-initiated CT services as well as those seeking VCT in health facilities, which is surprisingly common in Namibia. CT is now to be routinely offered to pregnant women, TB patients, STI patients, and patients with suspected HIV-related symptoms, but capacity remains limited compared to the huge demand. Community counselors, who receive a 6 week didactic and 6 week practical training, are being certified to perform rapid testing. Quality assurance results thus far show essentially 100% concordance with ELISA. In the first 6 months of FY06, which was the start-up phase of the program, community counselors tested more that 27,000 patients. Emphasis in FY07 will be to make at least one counselor available to most clinics, 2-3 per health center, 3-5 per small hospital, and 10-15 per referral hospital. Counselors will be equipped to deal with clients in a range of settings including PMTCT, TB clinic, ART clinic, and general outpatients. Training will be enhanced to include prevention with positives, couples counseling (ART clinic is the most common scenario in which this is needed in Namibia), and risk reduction. The additionally trained community counselors support a more integrated system through strong linkages to health facilities and the community, aiming to strengthen community and institutional linkages as well as referrals over the long term.

Program Area Target: Number of service outlets providing counseling and testing according to 217 national and international standards Number of individuals who received counseling and testing for HIV and 189,373 received their test results (including TB) Number of individuals trained in counseling and testing according to national 1,193 and international standards

Table 3.3.09:

Within COP07, funding for Community Counselors, who dedicate part of their time to this activity, is distributed among six program areas, all of them Ministry of Health and Social Services activities: Preventing Mother to Child Transmission (7334), Abstinence and Be Faithful (7329), Other Prevention (7333), HIV/TB (7972), Counseling and Testing (7336), and ARV Services (7330). This activity also links with Counseling and Testing activities of inter-faith Intrahealth (7405), Potentia (7343) and I-TECH (7351), and CDC's system strengthening activity (7360).

This activity is a continuation of FY06 activities and includes four primary components: (1) Training and deployment of Community Counselors, (2) procurement and distribution of HIV test kits, lancets, and supplies, (3) promotion of counseling and testing through Namibia's first ever National HIV Testing Day, and (4) professional development of MOHSS national counseling and testing program staff.

(1) Training and Deployment of Community Counselors ("Community Counselor initiative"). MoHSS established the Community Counselor cadre in 2004 to assist doctors and nurses in healthcare facilities with provision of HIV prevention, care, and treatment services, including HIV counseling and testing for PMTCT, TB, and STI patients as well as ART adherence and supportive counseling; and to link and refer patients from health care delivery sites to community HIV/AIDS services. Emphasis is placed on the recruitment of HIV positive individuals as community counselors as a strategy to reduce stigma and discrimination. To date, 175 community counselors (25% of whom are HIV positive) have been placed at 74 health facilities. With FY07 support, this number will increase to 430 by September 2007, and to a final target of 480 by December 2007. PEPFAR funding for the "Community Counselor package" includes: recruitment and salaries for the community counselors, 13 regional coordinators, and an assistant national coordinator (implemented through the Namibian Red Cross); initial and refresher training for community counselors (implemented by a local training partner); supervisory visits by MoHSS staff who directly supervise the community counselors; training for MoHSS accountants who are responsible for financial management of the program; support for planning meetings and an annual retreat for community counselors; and support for community counselor participation at international conferences.

Community counselors are the primary personnel at health sites responsible for providing HIV testing and counseling, providing pre-and post-test counseling and testing (using rapid tests) to support provider-initiated testing of PMTCT clients and their partners, TB and STI patients, and those with HIV-related symptoms. A large number of Namibians surprisingly also access health services for VCT services, which includes development of a risk reduction strategy and encouragement to bring in partners for testing.

(2) Procurement of HIV Test Kits and Supplies. With PEPFAR support, MoHSS will continue to purchase Determine and Unigold test kits (using a parallel testing algorithm) to be used at MoHSS and mission-managed sites for HIV testing of a projected 128,000 clients, using Hemastrip as a tie-breaker in rare instances of discordance; 60 HIV rapid test starter packs to launch new testing sites; and rapid HIV test training supplies for training community counselors. Test kits and supplies are procured and distributed to health facilities by the Central Medical Stores through existing mechanisms.

(3) Promotion of Counseling and Testing through National HIV Testing Day. MOHSS will again organize Namibia's first ever National HIV Testing Day in 2007. PEPFAR funds will be used to support promotional activities in all 13 regions, including drama presentations, radio announcements, other entertainment/educational events, speeches by national and local leaders, and production and distribution of print and electronic media. Billboards will be erected in 5 regions. Community partners such as the door-to-door campaign by Total Control of the Epidemic will be used to encourage people to test and to link them with the nearest counseling and testing facility. It is estimated that 50% or approximately 500,000 Namibians will be reached by mass media messages through this campaign.

(4) Professional Development of MOHSS National Counseling and Testing Program Staff. PEPFAR funds will be used to support attendance of 3 national-level program managers to make presentations at relevant regional and international HIV/AIDS conferences or meetings.

This is an expansion of FY06 and relates to other activities in this area, including MSH/RPM+ (7135), SCMS/Partnership for supply Chain Management (7449), and to ARV service activities, including those of Potentia (7339), the Ministry in Health and Social Services (MOHSS) (7330), and Intrahealth (7406).

The Central Medical Stores of the MOHSS is responsible for all ARV drug procurement and distribution in Namibia in the public sector, including mission-managed health facilities. As of March 2006, ART services had rolled out to all 34 district hospitals in Namibia, and by July 2006, Namibia had 22,000 persons on ART in the public sector alone. Children account for 16% of patients started on ART. ART services remain congested in these hospitals, and thus the current focus of the national ART program is to: 1) decentralize care and treatment, 2) focus on quality of care and treatment, 3) incorporate prevention and family planning messages into treatment, 4) improve "user friendliness" of ARV services, 5) improve linkages to TB and PMTCT services as well as with community-based organizations, and 6) increase the involvement of PLWHAs in palliative care and/or adherence support programs to strengthen the adherence strategy. It is planned to decentralize to at least 13 additional sites in 2007 and to have started more than 50,000 patients on ART by March 2008. Namibia has standardized first and second-line regimens. Approximately 70% of adults are currently on d4T/3TC/NVP or AZT/3TC/NVP, ~25% are on d4T/3TC/EFV or AZT/3TC/EFV, ~3% are on a TDF-containing regimen, and ~2% are on a protease inhibitor-containing regimen. However, the first edition of the national treatment guidelines are under review, particularly with respect to moving away from d4T due to toxicity. The financial implications of doing this, however, are still to be determined. Moreover, 13% of our adult patients are HepBsAg positive, yet only 3% of our patients are on an EFV-containing regimen. Efforts are underway to educate our clinicians to follow the guidelines and use EFV in such patients. It can be anticipated that greater use of TDF and EFV, as well as second-line treatment will increase the cost per capita in FY07 depending on the comparable pace of price reductions in ARVs over time.

In 2005, the MoHSS received $1.1 million from the USG for ARV drug procurement and successfully expended those funds on FDA-approved branded products using their Cooperative Agreement with HHS/CDC. A procurement plan for 2006 has been developed by the MoHSS and USG to use $3.6 million in direc funding and is being implemented. There were no FDA-approved generic products in the Ministry's tender for ARVs in 2005. However, the new MoHSS one-year tender for ARVs effective September 2006 will include 80% of the required budget to purchase FDA-approved generics, 6% for FDA-approved branded products, and the remainder for non-FDA-approved products. The possibility of using the Supply Chain Management System for any lower cost FDA-approved products on the current tender or in the updated guidelines is under review. At present the supply chain is working in Namibia, so the comparative advantage with SCMS could be in terms of price and in terms of access to ARVs which are currently non tendered for and would be very costly to buy locally off-tender. The Global Fund began support for ARV procurement in July 2005 with approximately $4 million in Year 1 and $9 million is expected to be approved in Year 2 (2007) as proposed in the Phase 2 Round 2 proposal currently under review. USG funds for ARV drug procurement in FY07 will strongly leverage resources with those of the Global Fund and MOHSS.

This activity relates to MOHSS ARV Drugs (7335); Potentia ARV Svcs (7339), the NIP (7975), I-TECH (7350), HRSA (7450), RPSO(7345); & CTS Global's Strategic Information activity (7323). The MOHSS health care network comprises 31 district hospitals, 4 referral hospitals, 35 health centers, and >240 clinics within hospital catchments. ART services and facility-based palliative were offered by 7 hospitals in 2003, 23 in 2004, and all 35 public hospitals by March 2006. According to the health information system (HIS), as of June 2006, a total of 36,828 patients are enrolled in palliative care in MoHSS facilities of whom 22,281 are on treatment.Since only about 70% of treatment facilities are included in the electronic HIS, the numbers are likely to be under-reported. Recent targets set by the MOHSS project 50,000 people on treatment by the end of Sept 2007, and 52,000 in care, 80% within the public sector network. The MoHSS is responsible for national coordination, resource mobilization, monitoring and evaluation, training, and policy development in support of all HIV/AIDS related services. MoHSS recognizes an urgent need to decentralize ARV services and transfer tasks from doctors to nurses. In this regard, a national policy review and curriculum adaptation workshop was held in early 2006 to localize WHO's Integrated Management of Adult Illness (IMAI) program. Each district hospital CDC will be responsible for the rollout of IMAI to one health centers or clinic in their catchment. Nurses in these sites will prescribe refills for ARVs for PLWHAs after the first 6 months of treatment at a district CDC. Many of the existing and future ART facilities are ill-equipped in terms of basic medical equipment and furniture. Lack of transport still impedes the ability of regional and especially district level supervisors to follow-up on the status of services in peripheral health facilities. Specifically, this activity includes 5 primary components: (1) Support to Ministry and mission-managed facilities including $3,690,243 for routine bioclinical monitoring tests (CD4, full blood counts, liver function tests, syphilis and Hepatitis B screening, renal function tests, other tests depending on regimen) performed by the Namibia Institute of Pathology for the estimated 50,000 patients still on ART by the end of March 2008 and for CD4 monitoring of non-ART patients enrolled in palliative care at communicable disease clinics (CDCs) and future IMAI sites. The Guidelines for ART Therapy in Namibia stipulate which tests are to be performed. The Global Fund does not provide financial support for bioclinical monitoring. 2) Support has been underway with MoHSS since 2004 to establish a new cadre of "Community Counselors" to assist doctors and nurses with provision of HIV prevention, care, and treatment services, including HIV counseling and testing, PMTCT, ART, TB, and STI; and to link and refer patients from health care delivery sites to community HIV/AIDS services. Emphasis is placed on the recruitment of HIV positive individuals from the health facility's catchment area as a strategy to reduce stigma and discrimination. To date, 175 community counselors (approximately 25% of whom are HIV positive) have been placed at 74 health facilities. With FY07 support, this number will increase to 430 by September 2007, and to a final target of 480 by December 2007. This is to enable most clinics to have at least one counselor, each health center 2-3, each district hospital 5-10, and each major referral hospital 10-15 counselors to serve the various departments. PEPFAR funding for the "Community Counselor initiative" includes: recruitment and salaries for the community counselors, 13 regional coordinators, and an assistant national coordinator (implemented through the Namibian Red Cross); technical assistance at the national level; initial and refresher training for community counselors (implemented by a local training partner); and supervisory visits by MoHSS staff who directly supervise the community counselors. Within COP07, funding for Community Counselors, who dedicate part of their time to adherence counseling, is distributed among six program areas, all of them MoHSS activities: PMTCT (7334), AB (7329), OP (7333), HIV/TB (7972), CT (7336), and ARV Services (7330). This activity also links with CDC's system strengthening activity (7360). Through serving in Ministry Communicable Disease Clinics, Community Counselors are an important source of information and adherence counseling to ART patients. They also assist health professionals with basic administrative tasks in the clinic and language interpretation for those who do not speak a local Namibian language. (3) This component continues to fund anthropometric measurements, monitoring, micronutrient supplementation, and minimal targeted nutrition supplementation for severely malnourished PLWHA who are on ART, including children. While MOHSS policy does not allow for provision of food to outpatients, it welcomed a collaboration with the Namibian Red Cross Society (NRCS) to refer for micronutrient supplementation and minimal targeted nutrition supplementation for severely malnourished PLWHA who are on ART and are referred by the Communicable Disease Clinics. The NRCS already provides USG-funded community counselors to Communicable Disease Clinics to provide counseling

and testing and they will link patients with NRCS access points in the community. Using World Food Programme and World Health Organization entry and exit criteria for food supplementation, the NRCS will provide a nutrition upplement for either severely malnourished persons living with HIV on or eligible for antiretroviral therapy (ART) or any pregnant or lactating woman on or eligible for ART. From the 2007 projections for new ART patients, an estimated 10% of non-pregnant and non-lactating PLWHA, plus all pregnant and lactating PLWHA, will be eligible for a 6-month supply of a nutrition supplement. Based on these estimates, the programme seeks to target approximately 2,500 PLWHA. The NRCS will be responsible for procurement, supply logistics, storage, monitoring, and distribution of the supplements. NRCS and MOHSS will also collaborate to link recipients of the nutrition supplement with stainable exit strategies such as gardening projects and income generating activities in their community. 4) Procurement of basic furniture and equipment to support the 13 health centers and clinics who will be new providers of ART and care as part of decentralization of services (e.g. weighing scales, desk, chair, benches). Existing CDC's will also receive lactate and hemoglobin meters, digital thermometers, ENT scopes, infant and pediatric weighing scales, measuring boards, leveraging similar support provided by Global Fund. Based on need, some CDC's will also receive support for improving care of female HIV patients, such as examination tables for gynecologic examinations, examination lamps, and specula. The cost of this activity will be split 1/3 with MOHSS Palliative Care: BHCS and 2/3 with MOHSS ARV Services. (5) Procurement of an additional 11 vehicles to provide adequate support and supervision to facilities within the catchment area of the district hospital, trace defaulters, and strengthen existing outreach services, particularly the districts involved in the decentralization of ART services. This activity is coordinated and leveraged with the Global Fund, which is also supporting vehicle procurement, so that by 2007, all but two districts will have at least one vehicle to support HIV/AIDS care.

The plus up funds will support the purchase of medical equipment, wich will improve care provided in the clinics and decrease overall laboratory costs by avoiding the need to send out blood to the laboratory to test for hemoglobin, glucose and lactate levels of patients on antiretroviral therapy.

This is a continuation of activities from FY04, FY05, and FY06 relating to CTS Global (7322), CDC (7359), Potentia (7338), and ITECH (7355). TEvery second year the Ministry of Health and Social Services conducts a survey at ANC clinics nation wide to determine the prevalence of HIV in pregnant women. Using methods recommended by WHO/UNAIDS, estimates from this survey is used to estimate the prevalence of HIV in the general adult population 15-49 years of age. This survey provides critical information for policy makers, implementers, and partners seeking to ameliorate the HIV/AIDS epidemic in Namibia. This activity will support planning and implementation of the national 2008 HIV Sentinel survey in pregnant women. The activity has two components: (1) providing computer equipment, ART patient record forms, and form filing systems for capturing, processing, and disseminating routine ART/PMTCT/CT/TB data; and (2) providing a team of abstractors to collect data for the Longitudinal Surveillance of Treatment under the Emergency Plan (L-STEP).

As detailed in activity #7322 and the SI area overview, timely data collection, processing and reporting are essential to measure progress in the National Strategic Plan for HIV/AIDS and improve services through program evaluation and targeted evaluation. The USG is supporting the MoHSS with personnel (activity #7338) and training (activity #7355) to facilitate these data collection, reporting, and program evaluation initiatives. This activity will provide equipment (computer and networking systems, internet communication, patient forms, and office supplies) to ensure data clerks and government HIS officers are able to collect and transmit data efficiently. It will also supply interviewers/data abstractors for L-STEP.

1. Computer equipment and patient record forms for collection and dissemination of routine ART/PMTCT/CT/TB data: This is a continuation of activities from FY04, FY05, and FY06, it relates to #7322, #7359, #7332, and #7338. The following items will be procured in order to continue and expand the capture, processing, and dissemination of routine ART/PMTCT/CT/TB data. It will ensure computer equipment and patient forms are available and in working order for both newly recruited and established data capture and processing personnel.

(a) Computers including monitors, printers, and uninterrupted power supplies will be procured for 28 new staff with HIS/M+E responsibilities (data clerks, data analysts, program administrators). In addition, 11 new computers will be procured to replace any of those now used around the country that fail (assumed to be 10% of all systems currently operating with PEPFAR support). 14 laptop computers for use in travel will be procured for M+E program administrators (3), data analysts (4), senior data clerks (3), L-STEP coordinator (1) and L-STEP data abstractors (3). (b) Computer replacement parts and software upgrades are budgeted to maintain optimal productivity. Memory sticks for ease of transferring files will be purchased for use by all SI staff. (c) Rapid, efficient, secure exchange of data is critical to program monitoring and improvement, but it remains a challenge in Namibia. This activity will provide secure email access (including telephone lines, Internet Service Provider subscriptions, and telephone bills) to all facility and regional data clerks. (d) In FY06, books of patients forms were assembled, and new books are budged for FY07 for patients newly registered for ART. The forms for collecting treatment monitoring information on all patients receiving care at public facilities were approved by the MoHSS technical advisory committee on ART. Approximately 12,000 patient books will be required during FY07. (e) This is a new sub-activity in FY07. Funds will be used to purchase a national-level license for new software for collecting and reporting ART, PMTCT, CT, TB data. The current software system is due to be phased out in FY07. The actual software product is being decided by technical experts and finalized with a consensus-building process. (f) This is a new sub-activity in FY07 which will establish a wireless network within the country's largest hospital (Katutura) to facilitate clinical patient management via rapid communication between the clinics, laboratory, and pharmacy; and another wireless network to faciliate communication between two MOHSS facilities, one housing the antional level HIS and the other the national level M&E system. The use of these relatively inexpensive technologies (compared with hardwiring) will facilitate exchange of ART, PMTCT, CT, TB information among clinics, laboratories, pharmcies, and the national level. Softward and operating systems for these networks will be selected through the consensus

development process outline in #7359 and the overal MIS migration described in #7322. Support from high levels of the MoHSS (under Secretary), in additon to the obvious benefits of a unified system, will help overcome the logistical challenges and promote sustainablity of this effort.

The second wireless network will allow information exchange among M+E and HIS personnel at the national level. Currently data necessary for HIV program evaluation is often not available to the M+E personnel and program managers who need to use it as data is collected by a different department with no shared network between them. The proposed network will allow secure sharing of information between these departments.Design of both these networks will receive support from a CDC network specialist based in South Africa who will consider the longer term needs of the Ministry.

(2) Surveyors and data abstractors for L-STEP: This is a continuation of FY06 and relates to #7338 in which Potentia will hire a coordinator for the project Longitudinal Surveillance for Treatment under the Emergency Plan (L-STEP) and to #7322 in which CTS Global will support an HIS technical advisor. Collecting and analyzing information on the same individuals over time is essential. Basic clinical data is routinely collected in Ministry-approved patient records and electronically entered by CDC-supported data clerks at the ART sites, but additional data will be required for L-STEP. L-STEP was established in FY06 as a system of longitudinal surveillance of a sample of adults and children on ARV therapy at treatment sites receiving Emergency Plan support, to provide standardized cohort information on treatment retention, drop-out, and death, regimen adherence and change, change in health status indicators (weight, function), co-infection with active TB, receipt of a basic package of HIV care services, and development of HIV drug resistance.

This activity will also support a team of 3-4 data abstractors (students from the national university on summer holidays) and interviewers who will visit a sample of USG-funded treatment facilities throughout the country to obtain information necessary for L-STEP. The Potentia-hired coordinator will complement the CDC-supported HIS advisor and M+E advisor currently in the field.

This activity is a continuation of FY06 for limited scholarships to train Namibian students to become health professionals. It relates to other activities in this Program Area: I-TECH (7352), Potentia (7341), and American International Health Alliance (8000).

Without question, inadequate human resource capacity is the leading obstacle to the development and sustainability of HIV/AIDS-related health services in Namibia. As of August 2006, the vacancy rate in government positions in the Ministry of Health and Social Services (MoHSS) was 40% for doctors, 60% for pharmacists, 48% for social workers, 25% for registered nurses, and 30% for enrolled nurses. Doctors, pharmacists, and medical technologists cannot be trained in Namibia due to the lack of a medical school and other training institutions. To fill urgently needed nursing and pharmacy positions, this activity will support MoHSS plans to increase the output of enrolled nurses and pharmacy assistants from the National Health Training Center, who can be trained in two years instead of four years, and for registered nurses at the University of Namibia. A total of 277 doctors, pharmacists, pharmacy assistants, nurses, enrolled nurses,laboratory technologists, and social workers will be trained in Namibia, South Africa, Zimbabwe, and Kenya. Students are bonded to serve the MoHSS upon completion of studies and will work in an area related to HIV/AIDS.

The funding of $25,000 will go towards expanding upon a new activity funded by the Plus-up; a men's conference lead by the Ministry of Health and Social Services to be held in August/September of 2007. After conversations with key individuals and policy makers in the MoHSS, it was decided the way forward to both intimately involve as well as strategically address men's roles in stopping the spread of HIV/AIDS was to solicit their feedback on a variety of topic. in order to adequately develop strategies to address male norms and behaviors. This conference is being planned in conjunction with the work Namibia is undertaking as part of the OGAC Gender/Male Norms initiative. During this conference, identified religious, cultural and targeted most at-risk men will come together to discuss their perception of their role in HIV prevention, care and treatment. The additional male circumcision funding is being added on to this activity in order to leverage the inertia from such a novel event and expand the conference by two to specifically address male circumcision. This will give time for the evidence base to be adequately presented, the recently released normative guidance discussed and then time to learn about the issues emerging around acceptability of male circumcision as a prevention intervention as well as address any identified barriers to rolling out MC services. The value of this conference will be the mix of policy makers with religious and cultural leaders in order to get a comprehensive view of the complexity of this issue specific to Namibia. Such a platform is unique to Namibia and we will leverage it by programming the remainder of the MC allocated funds (25,000) to bring in experts and regional teams from other SADC countries with more experience in dealing with rolling out MC services in order to share lessons learned and increase the local knowledge base.

With the initial funding ($80,000) from OGAC's South-to-South Initiative, the PEPFAR teams in Angola and Namibia propose the following activities:

Angola implementing partners and the Ministry of Health and Social Services (MOHSS) Namibia will enhance an already established relationship to form a mentoring program to strengthen PMTCT service access and coverage, improved quality of care and better outreach and follow-up for ART service delivery in the border regions. This mentoring program will involve exchanging experience, technical skill transfer, and health work protocol training achieved through cross-border visits by regional and provincial Ministry of Health delegations.

It will build on initial staff visits and exchanges carried out with support from WHO in 2006, as well as a new PMTCT initiative initiated in 2007 by USAID with the Cunene Provincial Health Department, CUAMM, Chemonics and other partners, which will expand PMTCT, safe birthing and reproductive health care services to expectant mothers in pre-birth waiting stations at one or more Angolan MOH health centers/maternity hospitals. MOHSS Namibia personnel will be supported in association with the Centers for Disease Control (CDC) Namibia. Angolan MOH and NGO staff will visit selected facilities in Ohangwena, Oshakati and other Namibian locations, and will participate in training organized with the support of the MoHSS, USAID and CDC. MOHSS Namibia personnel will conduct organized site visits at facilities in Ondjiva, Cahama, Santa Clara and other

municipal locations, and share recommendations on better application of best practices and international protocols, including their success at capturing mothers for institutional births. Training activities for MOH and NGO staff in both countries will be coordinated with and seek to leverage resources available under the current bilateral Global Fund programs in Angola and Namibia.

Ensuring the participation of individuals fundamentally responsible for the start-up and roll-out of PMTCT services in Namibia will be a key strategy employed to ensure lessons learned from Namibia are transferred to Angola. Other areas of importance in to which we envisage this expanding include, but are not limited to, VCT and TB (particularly in light of the worrisome anecdotal evidence of both XDR and MDR TB in Namibia), which may be incorporated subsequently in the FY08 COP planning processes.