In FY07, the USG will to continue to work closely with the Ministry of Health and Social Services (MoHSS) at the national, regional and service levels in the 34 health districts to provide technical expertise during the roll-out and strengthening of PMTCT services, to monitor the implementation at existing service delivery sites, to conduct the first formal evaluation of the program, and to support expansion of services from 165 clinical sites in March 2006 to 287 sites by the end of 2007. This is a continuation of FY06 and is closely linked with MoHSS_7334, Potentia_7344, I-TECH_7354, NIP_7927, and IntraHealth_7430 PMTCT services.

Namibia began PMTCT services in early 2002 at two public hospitals. In late 2002, the Global AIDS Program of HHS/CDC began its collaboration with Namibia;s MoHSS by providing technical assistance in PMTCT, VCT, TB/HIV, surveillance, and ART services. Due to severe staff shortages, no full-time MoHSS coordinator for the new national PMTCT program could be identified. Responsibilities for establishing, coordinating, and rolling out of PMTCT services were assigned to a manager in the Reproductive Health Unit in late 2003, who was already tasked with the national program for maternal mortality and family planning. Part-time technical assistance was provided to the Ministry's Coordinator by the HHS/CDC Country Director until a full-time USG-supported PMTCT technical advisor was assigned in late 2004 through I-TECH. A full-time national PMTCT coordinator was not assigned until April 2006.The USG also supports training, information systems, logistics and technical assistance to the national PMTCT program.

Specific activities include:

(1) Funding for two HHS/CDC PMTCT field support nurses as Foreign Service Nationals (FSNs). Working with Ministry staff at the national, regional, and district-level, these nurses conduct crucial supervisory support visits to current and upcoming PMTCT sites to provide on-site monitoring, training, and assessment of the quality of services, patient flow, record keeping as well as challenges and needs. The roll-out of rapid testing in PMTCT sites will also require hands-on support to health facilities. This staff also support sites to integrate the wide range of HIV prevention, treatment, and care services into the clinical setting and improve linkages with local non-governmental organizations (NGOs). Approximately 25% of women do not deliver in a health facility and these nurse supervisors will assist with the identification and training of traditional birth attendants (TBAs) in PMTCT. They will be located in Oshakati Hospital, the largest hospital in the north, where the Ministry has allocated office space to HHS/CDC in order to facilitate logistical, material, and technical support to this area where the majority of the population resides. CDC PMTCT field nurses will partner with other programs to identify needs, facilitate and implement supportive programs. They will offer TA to sites in a coordinated way, so as not to duplicate services provided by others. This activity leverages resources with the Global Fund, which is funding a PMTCT Coordinator, training, diagnostic PCR testing, and three PMTCT trainers at the national level.

(2) Support for travel of: - selected Namibian staff in the PMTCT program to attend relevant informational meetings and conferences on PMTCT in Namibia and in the southern Africa region to learn from best practices in neighboring countries. - MoHSS and USG counterparts to the 13 regions to conduct supportive supervisory visits to improve and expand PMTCT services. - An external USG-supported team for the evaluation of the national PMTCT program.

The provision of family planning (FP) for persons living with HIV/AIDS and others at-risk is also a primary prevention strategy for mother to child transmission. However, FP needs, particularly for HIV+ women and their partners, have been largely overlooked in Namibia. Contraceptive use among Namibian women is high (38%), but anecdotal evidence suggests that women on ART are becoming pregnant unintentionally. This not only has implications for the mother's well-being but also for pediatric AIDS. Many women are also thinking of having another pregnancy and would like to discuss their options with their service providers. Namibian health workers are willing to address FP, but they are often constrained by a lack of information, training and clarity on messaging. HIV clinics lack clinical guidelines/protocols and IEC materials, as well as a formal referral system for FP. Knowledge gaps exist among clinic staff; many HIV staff do not understand the concept of dual protection, while FP staff often believe their clients are at low risk for HIV.

This funding will support the development, translation, printing and distribution of IEC materials related to FP topics. Before development of new materials occur, a group of stakeholders will meet to review existing IEC materials from other countries to determine whether existing materials can meet the needs. This activity will also support a similar effort to review, update, print, and widely distribute FP guidelines for Namibia. IEC materials and FP guidelines will be made available to government and FBO health care facilities, health care workers at military bases, and organizations carrying out health promotion activities.

This is a new activity for FY07 and includes two components, namely (1) the provision of a new proposed CDC technical advisor on HIV prevention and behavior change to the Directorate of Special Programs (HIV/AIDS, TB, and Malaria), Ministry of Health and Social Services (MoHSS), and (2) travel in support of several technical assistance visits from CDC Headquarters concerning the following prevention interventions: prevention with positives, male involvement, parental involvement in prevention, and the role of alcohol in HIV prevention.

In late 2002, the Global AIDS Program of HHS/CDC began its collaboration with Namibia by opening an office in the National AIDS Coordination Program (now known as the Directorate of Special Programs), MoHSS to provide technical assistance in PMTCT, VCT, TB/HIV, surveillance, and ART services. In response to requests from the Ministry, CDC has gradually formed a team of 7 technical advisors at the national level, including two direct hires, in the areas of care/treatment, including pediatrics, PMTCT, VCT, SI, and laboratory services. While the Ministry has made substantial progress in terms of rolling out treatment, PMTCT, and VCT, we are all cognizant that less attention has been given by the Ministry and USG to the development of a comprehensive systematic national prevention strategy based on best practices and evidence-based interventions. Primarily through the leadership of the Ministry of Information and Broadcasting (MIB), which receives substantial USG support, an active prevention campaign known as "Take Control" has been in place for a number of years. The MoHSS, which is the technical lead and coordinator of all sectors in HIV prevention, however, has not had a HIV prevention focal person to provide technical leadership and vision on prevention issues. The new Director, Directorate of Special Programs, recognizes the shortcomings and lack of leadership which MoHSS has shown in prevention and requests the support of a behavioral scientist to build local capacity in the use of evidence-based approaches to design national prevention programs. This comes at the same time that the Ministry is staffing the "Expanded National Response" subdivision within the Directorate which is tasked with behavioral change and strategic communications. Therefore, the local environment is well suited for the introduction of a USG Technical Advisor (TA) on prevention.

The proposed TA will serve as the focal person for USG-supported prevention initiatives involving the MoHSS. Namibia lacks standardized evidence-based nationwide approaches to prevention, including "prevention with positives" (though this is getting underway in 2006), male involvement (though this too is getting underway in 2006), parental or family involvement in educating their children on reproductive health and HIV/AIDS (though there are scattered varying approaches used by FBOs), and educating the public on the risks associated with alcohol and HIV. The Ministry needs to develop capacity to provide national leadership on the most evidence-based prevention strategies available, including behavioral change interventions and medical interventions (eg, circumcision, microbicides, etc) as they become available, but this urgently needs strengthening. The TA will support a process to adapt best practices from other countries and to promote dissemination of best practices from within Namibia at the national level. This will include support to the head of the Counseling and Testing unit in the Directorate to roll out, monitor, and evaluate the prevention with positives intervention through community counselors and health workers. This will include supporting the male involvement program, with particular emphasis on defining and promoting strategies that result in male partner reduction. The evidence-based "Parents Matter" or "Families Matter" approach will be adapted to the Namibia context to create a locally relevant toolkit that willing organizations can put into practice. It is critical that adolescents be taught about responsible sexual behavior by their parents or close relatives taking local cultural practices and norms into account.

This new activity will cover travel in FY07 for CDC technical assistance to the Ministry to strengthen guidelines and facility interventions to prevent nosocomial transmission of TB and to complete the transition from the Epi Info 6 version of the Electronic TB Register to the Windows version of the software. It relates to Royal Netherlands TB Association, ITECH, and CDC Systems Strengthening.

In late 2002, the Global AIDS Program of HHS/CDC began its collaboration with Namibia by opening an office in the National AIDS Coordination Program (now the Directorate of Special Programs for TB, HIV, and Malaria), Ministry of Health and Social Services (MoHSS) to provide technical assistance in PMTCT, VCT, TB/HIV, surveillance, and ART services. At the time there was but one Ministry staff member in the National TB Control Program (NTCP), but there has since been added a USG-funded TB Technical Advisor, 2 additional program managers, a Global Fund-funded coordinator for community-based TB initiatives, and two Global Fund-funded data clerks to support the Electronic TB Register. The NTCP has since developed their first Medium Term Plan and updated their TB guidelines to include routine offer of HIV counseling and testing, isoniazid preventive therapy (IPT), cotrimoxazole prophylaxis for TB/HIV co-infected patients, and management of TB treatment and antiretroviral therapy (ART).

Two of the many challenges facing the NTCP are instituting practical measures to prevent nosocomial transmission of TB, particularly to HIV-infected patients, and strengthening of the surveillance system for TB/HIV. In FY07, CDC will support the NTCP to conduct an assessment of health facilities and prepare an action plan for bringing Namibia in line with current WHO/CDC recommendations. Emphasis will be placed on sites with higher rates of MDR-TB and in locations where patients with undiagnosed and untreated cough are managed to minimize exposure to HIV-infected patients and health workers. The CDC team in the Ministry will support the NTCP with implementation of the plan once developed to ensure that action steps are followed.

Namibia is one of several southern Africa countries who adopted the Electronic TB Register based in Epi Info 6 that was developed by the BOTUSA Project (Botswana-CDC collaboration) in Botswana. Effort will begin in 2006 to migrate this system to the Windows-based version ETR.net as developed in South Africa with USG support. Additional TA will be provide in FY07 to follow through with the adaptation and migration process, including training of end users in the district TB program offices and at the regional and national for data management. The ETR will include information on HIV status and use of ART in TB/HIV patients.

This activity leverages resources with the USAID-funded TBCAP and with the Global Fund Round 2 and Round 5 support to the Ministry.

Namibia has the highest rate of tuberculosis in the world and TB currently is the leading cause of death for persons with HIV. In addition to multidrug resistant TB, Namibia is facing the added challenge of identifying and responding to the potential emergence of extreme drug resistant TB, first recognized in neighboring South Africa. This activity will support technical assistance from the American Society of Microbiologists (ASM) to the Namibia Institute of Pathology (NIP) to build TB expertise. Specifically, ASM will provide one or more expert technologists to work closely with the new TB QA Technologist within NIP and the NIP Training Unit Coordinator. This assistance is critical as these are new positions within NIP and are responsible for improving the expertise of the NIP technologists. Furthermore, NIP is in receipt of new instruments (MGIT 960s) and ASM will play a key role in ensuring that NIP technologists are proficient in using this equipment, as well as assisting with the expansion of TB laboratory capacity two two new sites, Walvis Bay and Oshakati. The ASM consultants will further assist NIP with the a planned TB drug sensitivity testing survey.

This activity will cover the costs to perform genotypic HIV resistance testing at HHS/CDC in Atlanta on samples collected at sentinel surveillance sites. The purpose of this activity is to increase the capacity of Namibia to establish surveillance for drug-resistant HIV. Rather than attempt to introduce genetic sequencing at the Namibia Institute of Pathology (NIP) at this time, which is not feasible, linkages will be expanded with other established laboratories to perform sequencing while building the capacity of the Ministry and NIP to set up surveillance protocols and procedures, process specimens and complete RNA extraction, ship specimens, analyze and interpret results, and make recommendations to strengthen surveillance and the national ART program.

Submission of samples to a private laboratory in South Africa is too costly and will do less to build local capacity within NIP, so collaboration with HHS/CDC-Atlanta is under review.

The rapid scale up of provision of ART services in the country has placed a strain on the laboratory infrastructure and the capacity of the NIP to respond effectively. Consequently, the USG (see Comforce/Lab Infrastructure #7323) has recruited a laboratory scientist with a background in molecular HIV technologies to build capacity at NIP to perform diagnostic PCR testing and to help improve lab protocols and standard operating procedures. This scientist will facilitate protocol development, provide technical support, and help to link the NIP with established laboratories. More than 22,000 Namibians are now on ART in the public sector and the quality of ART prescribing practices for the 5,000 patients in the private sector is often substandard, yet little is known about the extent of drug resistant HIV in Namibia. Access to resistance testing for surveillance and for capacity building within the NIP is therefore a priority. Funds for this activity will be carried over from leftover HIV resistance testing FY06 funds.

This activity is a continuation and expansion of FY04/FY05/FY06 and also relates to CTS Global (7322), Ministry of Health and Social Services (MoHSS) (7332), Potentia (7338), and ITECH (7355).

The emphasis of this activity is to support the MoHSS National Health Information System (HIS) and the Monitoring and Evaluation Units of the National AIDS Programme in collection and use of HIV surveillance data as well as routine data from HIV/AIDS-related programs. This activity will continue to provide expert consultants to advise the MoHSS on HIV/AIDS database development, training on general concepts and practices of M+E, training in surveillance as a specific component of M+E, and laboratory analysis support for ARV drug sensitivity testing.

1) Database Maintenance and Development: Development and maintenance of efficient databases to capture indicator information is critical to monitoring and evaluation of HIV/AIDS programs. Since 2003 the USG has provided short and long-term technical assistance to the Ministry for ART, PMTCT, TB, and VCT database development and maintenance. This activity will continue systems development support to the MoHSS in FY07 to advise the Ministry as it upgrades and improves these systems to facilitate better patient management and program reporting. This support will draw on PEPFAR experience in other countries to identify pre-developed software tools that may be appropriate for implementation in Namibia.

2) Trainers for surveillance and M+E training workshops: Capacity in collection and use of indicator information, essential to effective program M+E, is severely lacking in the MoHSS. In addition, though routine ANC surveillance has been carried out regularly since 1992, understanding of methods for collection and interpretation of this information is weak. Experts identified through CDC/HQ will conduct training workshops in M+E and surveillance to build capacity in these areas. These trainers will conduct 4 M+E training workshops each including 30 trainees and 1 surveillance training workshop with 20 trainees. ITECH (7355) describes the personnel targeted for these workshops and coordination mechanisms through which they will occur.

3) Short-term training seminars for MoHSS M+E/HIS personnel: Lack of formal training and experience in MoHSS M+E and HIS personnel impairs their ability to capture, process, and use data. Building capacity in these personnel is one of the most effective means to increase efficiency in collecting, processing and using SI. Through this activity, higher level M+E and HIS personnel working for the MoHSS (program administrator level or above) will attend national and international workshops to prepare them better for technical and managerial responsibilities as well as to enable them to be effective "trainers of trainers" so the knowledge and spread and thus build SI capabilities at all levels. Capacity development will emphasize evaluation techniques to promote meaningful use and presentation of the data available to impact program delivery and policy decisions.

4) Drug Sensitivity Testing: Samples will be collected from routine HIV care and treatment services, and these will be sent to Atlanta where ARV drug sensitivity testing will take place. These activities will follow a standard international protocol that will be modified to suit the Namibian context and approved by a Namibian ethical committee (IRB).

Each sub-activity described above is designed to promote public health evaluation for program and policy improvement. TA for database development will facilitate more efficient collection and processing of HIV/AIDS data so it is available for public health program evaluation and improvement; Training workshops and seminars will highlight program evaluation methods to help improve service at both the local and national levels. ARV drug sensitivity testing will support public health evaluation by identify if there are any areas in the country where first-line ARV drugs may be losing their effectiveness and where adherence programs should be strengthened.

The CDC Systems Administration department runs a mail server and network used by the whole of the Namibian National AIDS Coordination Programme (Ministry of Health and Social Services). This require a dependable power supply. This activity will procure an uninterruptable power supply unit that will support the CDC server equipment to protect that equipment in the event of a power outage.

This activity is a continuation of FY05 activities. Since it includes partial support for the HHS/CDC Country Director and Deputy Director, Programs, this activity relates relates directly to all HHS/CDC activities and to all USG activities as part of the PEPFAR team in Namibia. The Deputy Director, Programs will continue to spend most of her/his time working in the Directorate to establish and roll out guidelines and policies and provide field support.

In late 2002, the Global AIDS Program of HHS/CDC began its collaboration with Namibia by opening an office in the Directorate of Special Programs (TB, HIV/AIDS, and Malaria), Ministry of Health and Social Services (MoHSS) to provide technical assistance in PMTCT, VCT, TB/HIV, surveillance, and ART/care services. The Country Director's time has been mostly spent assisting the Deputy Director, Health Services (TB, HIV/AIDS, and malaria), Directorate of Special Progams, with the development of national technical policies and guidelines, strategic planning for the rollout of new services, workplans for the Directorate, and field guidance and support. To date, the Directorate has been supported to: develop ART, PMTCT, and TB/HIV guidelines and a national rollout plan for these services, guidelines for the selection of community counselors to provide CT in the clinical setting, a rapid HIV testing policy, the HMIS for PMTCT and ART; conduct HIV sentinel surveillance; and complete support visits to all ART sites.

The emphasis during FY06 will include updating the ART guidelines, strengthening the ARV regimen for PMTCT, integration of services, strengthening palliative care and pediatric treatment, introducing the incidence assay into HIV sentinel surveillance and surveillance for drug-resistant HIV, accelerating the rollout of rapid HIV testing and community counselors, and further leveraging of resources with the Global Fund.

Digital video conferencing (DVC) has proven to be a very successful tool in getting much needed HIV-related training to persons providing health and social services to patients with HIV/AIDS. Namibia has one of the highest rates of HIV in the world. It is also the 2nd least populated country in the world. In Namibia, many clinicians and other caregivers provide services in rural areas. Currently, DVC training is provided in six sites throughout the country. Despite this coverage, these sites are not easily accessible to HIV caregivers, requiring extensive travel times and significant expense as traveling to some sites require an overnight stay. This activity will fully equip four new sites for DVC training, including: (1) Grootfontein/Tsumeb, (2) Swakopmund/Walvis Bay, (3) Gobabis, and (4) Luderitz. Equipment to be procured includes DVC camera, television, stand, video machine, ISDN points and installation, curtains, PRI line upgrade and installation, and security. By establishing these new sites, providers in the northeast, west, southeast, and southwest will have greater access to HIV-related training by the end of 2007.

These activities encompass efforts to maintain or enhance programming as well as to provide staff with ongoing opportunities to expand their knowledge, skills and abilities.

These efforts include support to HHS/CDC staff through the provision of housing costs for direct hires and general office administration. Included in general office administration are telephone services, computer consumables, and office supplies. The activities will support the costs of in-country travel for staff to attend meetings, to facilitate communication with regional and district officials, and to monitor CDC-supported efforts in the field.

In FY07, 2 new ASPH fellows will embark on 2-year assignments within the HHS/CDC office. One fellow will assist with management and administration of the cooperative agreements; the other will provide strategic information support to the new Emergency Plan Coordinator. The HHS/CDC office has identified these positions as essential to enhancing efficiency and communication within the PEPFAR team and with cooperative agreement partners.

Staff development efforts will include support for HHS/CDC team members to attend training, in-services and conferences either in person or by videoconferencing to learn about the latest developments in their respective fields.