According to the 2006 national sentinel HIV sero-prevalence survey, the HIV prevalence in Namibia

increased from 4.2% in 1992 to 19.9% in 2006. The estimated number of pregnant women in 2006 was

61,000 (Central Bureau of statistics) and 90% of these pregnant women had at least one ANC visit and of

those 72% delivered in a health facility. Based on the current HIV prevalence rate of 19.9% among pregnant

women, 12,139 were estimated to be infected with HIV. Without intervention it is estimated that about a third

of infants (4,047) born to HIV-positive mothers would be infected with HIV. Thus PMTCT is a national and

USG priority.

The program focuses on primary prevention of STI's including HIV in women of reproductive age;

prevention of unintended pregnancy in HIV-infected women; prevention of mother-to-child transmission

through the use of antiretroviral (ARV) medicines and other practices such as exclusive breastfeeding or

exclusive replacement feeding and provision of comprehensive care to HIV infected women, partners, and

early diagnosis for infants. A national opt out testing strategy was adopted and integrated within the national

PMTCT guidelines and training curriculum in 2004. To date 2128 healthcare workers have been trained in

provision of PMTCT services. 90% of pregnant women attending the current PMTCT are counseled and

85% tested at first ANC visit. In addition, with support from the USG, rapid HIV testing is also now available

in 94 public health facilities, which contributed to the increase in the proportion of women who knew their

HIV status at the time of delivery from 58% to 77% in 2006.

The PMTCT program receives funds through different partners including Global Fund (GF) and the USG.

Thus far I-TECH and GF have trained 2,128 healthcare workers on the provision of PMTCT services. To

strengthen the quality of service provision at facility level, I-TECH has conducted 181 support visits since

the start of the program. With FY 2008 funds, I TECH will continue providing support for the MOHSS and

GF to conduct 50 PMTCT support visits. The purpose of these visits is to provide on-site supportive

supervision and to identify challenges and gaps that the healthcare workers may have encountered with

program implementation.

The single dose nevirapine (SD-NVP) regimen formed part of the national policy for PMTCT. The MOHSS is

currently reviewing and updating the National PMTCT guidelines in line with World Health Organization

(WHO) recommendations. To ensure consistency and quality of service provision, I TECH will therefore

update the training materials accordingly and will conduct a series of DVC sessions to orient HCW on the

new guidelines in FY 2008.

Basic PMTCT training will continue to be supported by GF. I-TECH in collaboration with MOHSS and GF

will develop a three day refresher curriculum to update PMTCT service providers who were trained in the

original curriculum. Due to the complex nature of the new ARV prophylaxis regimen, it is anticipated that a

large number of PMTCT service providers will require updating. To complement the basic PMTCT training

conducted by GF, I-TECH will provide refresher training to at least 100 HCW in FY08.

The national recommendation for HIV positive women is to encourage exclusive breastfeeding for the first

four months for mothers who may not meet the AFASS criteria. It is therefore essential that healthcare

workers are equipped to support mothers to make informed decisions and to provide appropriate

information about breastfeeding techniques, the management of breastfeeding problems and safer sex

practices. I-TECH will strengthen this by adapting the WHO infant feeding counseling tools and integrating

them into the training curricula for health workers use during infant feeding counseling sessions.

Counseling women on reproductive choices and family planning (FP) remains a challenge in Namibia. A key

contributing factor is the lack of guiding education materials/job aids for HCW to utilize when providing these

services. In FY 2008 I-TECH in collaboration with the MOHSS information, education and communication

(IEC) unit will adapt the WHO reproductive choices flip chart which contains information to support the

healthcare workers to provide appropriate reproductive choice counseling.

Rapid expansion of DBS testing to all health facilities is essential for early infant HIV diagnosis. In order to

improve to infant HIV diagnosis, laboratory capacity and an algorithm for doing diagnostic HIV1 DNA PCR

testing were developed for Dried Blood Spot (DBS) testing of HIV-exposed infants from six weeks of age. In

line with this algorithm, I-TECH developed and rolled out a curriculum for training health workers on DBS,

including pre-and post-test counseling and reinforcing messages on infant feeding. To date over 74 sites

have been trained to do DBS sampling using the DBS training curriculum. By March 2007, 4,202 infant

HIV1 DNA PCR tests were conducted and 52% of samples were collected using dried blood spot technique.

In FY 2007 I-TECH trained 146 HCW on the provision of Dried Blood Spot (DBS) for infant diagnosis. In FY

2008, I-TECH will train 200 new healthcare workers on DBS and an additional 200 HCW will receive a two

day refresher training on DBS. In addition in FY 2008 a DBS quality assurance laboratory technologist will

be recruited and deployed at the Namibia Institute of Pathology to oversee the scale-up and implementation

of the DBS program.

In a new activity for FY08, I-TECH will develop and carry out training for (1) a cadre of 34 newly hired

clinical case managers (Potentia/new), (2) Prevention with Positives for health care workers, and (3) training

for clinical staff on male circumcision.

Case managers will fall in the chain of command of the MOHSS Directorate of Special Programmes'

Director of Case Management. Priority assignment sites for these case managers will be ART clinics and

ANC sites, where they will provide adherence counseling, prevention with positive services, coaching of

patients regarding notifying and referring partners for HIV counseling and testing, following-up of patients

who "slip through the cracks", facilitation of support groups, and referrals to other health and social services,

including counseling for drug/alcohol treatment and domestic violence. Particular emphasis will be placed

on encouraging men to seek services and to support their partners and children in doing the same. These

case managers will have backgrounds in psychology. This activity will support the following components of

the minimum package of prevention services in a generalized epidemic: behavior change counseling, HIV

counseling and testing, condom distribution, STI treatment, PMTCT, male circumcision, and linkages with

care, support and treatment.

I-TECH will further be responsible for integrating CDC's PwP curricula into existing and future trainings for

health care workers. The PwP program integrates prevention counseling and services for people living with

HIV into HIV care and treatment clinics. HIV clinical staff will be supported in the integration of prevention

counseling and services for people living with HIV/AIDS (PLWHA) into HIV care and treatment clinics.

Specifically, health care providers and lay counselors in care and treatment settings will be trained to deliver

prevention messages during routine clinic visits using tools and job aids. In addition, clinical staff will be

trained to integrate prevention services into care and treatment settings, including family planning

counseling and services, identification and treatment of STIs, and prevention counseling provided by lay

counselors. The C/OP portion of this activity will include provider- and lay counselor-delivered prevention

messages promoting correct and consistent condom use during every sexual encounter. Also, condom use

will be encouraged during family planning counseling as a method of dual protection and to reduce STI

transmission and acquisition. These prevention messages and interventions will be delivered during risk-

reduction counseling, family planning counseling, and STI management and counseling. Condoms and

educational materials on correct condom use will be provided to all people living with HIV at all clinic sites.

This activity will support the following components of the minimum package of prevention services in a

generalized epidemic: behavior change counseling, HIV counseling and testing, condom distribution, STI

treatment, PMTCT, male circumcision, and linkages with care, support and treatment.

Thirdly, I-TECH will be responsible for training a select number of private and/or public health care workers

on performing male circumcision (MC). With FY07 funds, PEPFAR will support a MC feasibility assessment

that will inform the way forward in implementing an MC program in Namibia. As per WHO's MC guidelines,

such assessments should "describe and map out the anticipated scope of male circumcision scale-up,

human resource and training needs, infrastructure, commodities and logistics requirements, costs and

funding, and systems for monitoring, evaluation and follow-up." Though the assessment is not yet

complete, there is solid support for MC within the public and private medical communities of Namibia. In

anticipation that demand for MC will continue to increase, I-TECH will be funded to develop a clinical

training in MC, utilizing its existing network of clinical mentors to provide both didactic and practical training.

Given the time required to develop a curriculum and to properly train providers to maximize safety, training

will be targeted to 25 providers in FY2008. I-TECH's training program will not only incorporate clinical

delivery of MC, but also the prevention and aftercare messaging that completes the MC package. This

activity will support the following components of prevention services in a generalized epidemic: behavior

change counseling, HIV counseling and testing, condom distribution, male circumcision, and linkages with

care, support and treatment.

For all trainings above, funding will curricula development, printing costs, and equipment and supplies.

Additionally, I-TECH will be charged with logistical coordination for providing training, either by digital video

conferencing or in-person. In-person costs will include travel, housing, and meals and incidental expenses

for trainers and trainees.

For new and existing curricula and trainings, I-TECH will support the MOHSS' efforts in strengthening

prevention and treatment responses. Based on guidance from the Global Technical Working Group

sponsored by the Gates and Kaiser Family Foundations, ITECH will revise protocols and materials to

strengthen gender-sensitive HIV prevention counseling, access to condoms and other prevention tools, and

refer to CT and STI screening. Messages shall emphasize the importance of risk reduction and prevention,

and the limitations of ART. No additional funding for this element is required.

All of these programs will have support from the following resources: technical assistance in alcohol

counseling and screening (17057.08), and mainstreaming gender into clinical and community programs

(EngenderHealth 12342.08); and capacity building in behavior change communications (PHDC 16501.08).

This activity continues from FY 2007 and includes technical support for four elements:

1) Integrated Management of Adult Illness (IMAI) in Palliative Care:

National leadership and implementation for facility-based palliative care for people living with HIV/AIDS

(PLHWA) is in the framework of WHO's IMAI program for Namibia. In COP 2007, I-TECH and APCA

supported the Ministry of Health and Social Services (MOHSS) with further development of the IMAI

palliative care module to reflect the Namibian context and integration of palliative care expertise from other

African countries. Implementation and training will likely begin in COP2008. This will include training of

trainers (TOT) for nurses; adapting HIV-care related patient education materials for use in facilities and

communities; in-service and regional trainings that target the IMAI roll-out sites; and on-site support visits to

IMAI sites from Potentia staff (7340). Technical training and technical support will also be provided to health

providers in the private sector in partnership with the MOHSS and the HIV Clinicians' Society.

Results will include nurse provision of palliative care services at facility levels and improved linkages to

community-based palliative care services, including management of clients who are not yet eligible for ART

and clients who have received their first six months of ART at hospital-based Communicable Disease

Clinics (CDCs). Technical advancement for pediatric care will continue to be provided by the MOHSS

pediatric care and treatment training program and the MOHSS Integrated Management of Childhood Illness

(IMCI) program. In combination with the other IMAI modules and pediatric curricula, health care workers

(HCWs) will be able to address key elements of the preventive care package for adults and children

(cotrimaxole prophylaxis, TB screening and INH prophylaxis, integrated CT, HIV child survival interventions,

clinical nutrition, HIV prevention strategies), other OI management, ART adherence, routine clinical

monitoring and systematic pain and symptom management. Costs associated with the IMAI program are

shared with I-TECH activities.

2) Strengthened Integration of Prevention Strategies into HIV/AIDS Training:

This component builds on current efforts to strengthen HCWs ability to employ prevention strategies for HIV

-infected persons such as integrating simplified messages on prevention, family planning and alcohol

reduction, providing STI care, and making referrals. HCWs play a key role in helping clients to reduce HIV

risk behavior and are willing to address prevention strategies for HIV-infected persons, but they are often

constrained by a lack of information, training and clarity on messaging. ART sites lack comprehensive

guidelines/protocols and educational materials, as well as a formal referral system for family planning,

among other services. Sexually transmitted infections (STI) remained a major challenge in Namibia;

according to government report more that 7.5% of the population contracts an STI each year and a total of

82,725 and 67,414 new STI cases were reported in 2005 and 2006 respectively. STIs are syndromically

managed and surveillance is entirely paper-based, so these figures are unable to paint the true picture of

the STI burden in Namibia. While the MOHSS established an STI control intervention for syndromic

management, this program receives relatively limited support from partners and little progress has been

made in reducing the burden of STIs in the last years. In addition, existing STI guidelines (which are

currently being revised for an anticipated 2007 release) and training modules lack appropriate prevention

messaging, family planning and guidance on support for disclosure of STIs, including HIV status. With COP

2007 funds, I-TECH is collaborating with the MOHSS STI division to update its training to include

appropriate information and guidance on prevention messaging, disclosure, reduction in alcohol use and

gender-based violence. With COP 2008 funds, to update HCWs' knowledge and skills to reduce the burden

of STI in Namibia, I-TECH will use the updated training to conduct 20 ToTs and 7 regional trainings,

resulting in 260 trained HCWs from 13 regions. In addition, with COP2008 funds I-TECH will "Namibianize"

and disseminate Information Education and Communication (IEC) materials developed by other sources. I-

TECH has also partnered with the Primary Health Care Division in the MOHSS (who provides wrap around

funding for family planning) to develop a family planning/HIV training module and related IEC materials that

will be incorporated in the PMTCT and ART guidelines training. This work will be expanded in COP 2008 to

include training of 50+ HCWs on prevention for HIV-infected persons and the provision of FP and STI care

for PLWHA. These "Prevention with Positives" (PwP) trainings have been developed using materials from

CDC's PwP Initiative.

3). Clinical management of Opportunistic Infections:

Clinical management of OIs is essential to the well-being of clients living with HIV/AIDS. In COP2007,

ITECH trained 90 government physicians and pharmacists in clinical management of opportunistic

infections and 55 private practitioners will also have received such training by the end of COP2007. ITECH

will also participate in the MOHSS revision of the National Guidelines for the Clinical Management of HIV

and AIDS. With COP2008 funds, ITECH will provide training for an additional 75 government physicians

and pharmacists and 40 private practitioners based on the new MOHSS guidelines.

4) Nutrition:

Routine nutrition counseling, assessment and monitoring of malnourished PLWHA and children affected by

HIV continue to be a challenge in Namibia. There is a critical need to build Namibian capacity as there are

very few public sector nutritionists and one dietician in the country. Through PEPFAR funding, I-TECH has

placed a nutrition advisor in the MOHSS who has developed and implemented a four day training program

on HIV/AIDS and clinical nutrition for HCWs. Results to date include 217 trained HCWs who recognize

nutrition as a key component in delivering effective HIV treatment, care, and support services. I-TECH also

integrated clinical nutrition into several other HIV curricula, including ART, management of opportunistic

infections, dried blood spot PCR testing for early infant diagnosis, TB training for nurses, pediatric HIV

training for physicians, and PMTCT. In COP 2008, I-TECH will continue support for the nutrition advisor who

will support the MOHSS in oversight of training and skills development in HIV/AIDS nutrition management,

safe infant and young child feeding, and improved technical support and monitoring of trained HCWs. The

advisor will ensure implementation of the monitoring tools and IEC materials developed in partnership with

the Food and Nutrition Technical Assistance (FANTA) Project in FY 2007 as well as ensure procurement of

training materials and anthropometric monitoring equipment for ART sites. The advisor will also support

appropriate implementation of the MOHSS and Red Cross nutrition program which includes referrals for

nutritional supplementation for adults and children on ART. To enhance regional nutrition expertise, I-TECH

will recruit and deploy two regional nutrition mentors via Potentia. Under the supervision of the MOHSS and

the nutrition advisor, the mentors will guide initial and follow-up training, provide on-site clinical support and

follow up visits and serve as key technical assistance (TA) for the many community-based food and nutrition

projects. To ensure sustainability, regional nutrition mentors will be absorbed into MOHSS staff.

Activity Narrative: Continuation of the four day training for health workers is essential and COP 2008 funds will support training

for additional 175 health workers from the 13 regions. With funding from the Clinton Foundation for ready-to

-use therapeutic feeding (RUTF) and roll-out of a pilot program in COP2007, I-TECH will also support five

regional trainings for HCWs to identify and treat severe acute malnutrition (SAM) in HIV-infected children.

The goals are to improve: early detection of HIV status, timely management of (SAM) with leveraged RUTF

food support, entrance to pediatric ART, and referrals and treatment of HIV-related conditions in HIV

infected children. As part of a USG-supported partnership between I-TECH, MOHSS and the FANTA Follow

-On Project, an extended nutrition and HIV course will be developed in COP2008 to equip at least 13

regional HCWs to strengthen and supervise clinical nutrition in ART sites. These workers will focus on

supervising clinical nutrition assessment, improving counseling on safe infant and young child feeding,

expanding education on managing HIV symptoms and effective nutritional management with ART.

Development of the course will begin in COP2008. I-TECH will provide a trainer to facilitate the short-

course, materials and secure training venue, and the FANTA Follow-On Project will provide TA for

development of the course and integrating it into the newly funded certificate program in nutrition at the

University of Namibia (UNAM) or the Polytechnic of Namibia (PoN). ITECH, FANTA and MOHSS will also

work with either UNAM or PoN to develop a diploma program in nutrition which will be integrated into an

MPH degree program (OHPS TBD/new). The certificate program will result in a longer-term cadre of

Namibian professionals with a high level of nutritional knowledge who will fulfill the consistent clinical

nutrition human resource gaps for the MOHSS and other line Ministries, NGO and private sector partners.

This activity continues from 2007 and links to HVTB: Potentia (16193), MOHSS (16154), and TBCAP

(16210), as well as HBHC: DAPP (16121), Pact(16179), and I-TECH (16218).

Namibia ranks 2nd in the world for incidence of tuberculosis (TB) with a rate of 765 cases/100,000

population (MOHSS 2006 Annual Report). Not surprisingly, TB/HIV co-infection is also a major challenge in

Namibia. In 2006, 30% of TB patients nationwide were tested for HIV, and of those 67% were HIV-positive.

The Ministry of Health and Social Services (MOHSS) launched new Namibian TB Management Guidelines

in March 2006. The guidelines support the Directly Observed Treatment (DOT) strategy which had a

number of initiatives, including increased placement of DOTS points in community settings and introduction

of Fixed Dose Combination (FDC) medication to improve adherence. With technical assistance from the

International Training and Education Center on HIV/AIDS (I-TECH) and the TB Control Assistance Program

(TBCAP), the National HIV Training Center (NHTC) of the MOHSS incorporated a chapter on HIV/TB co-

infection into its national training curriculum. Within this chapter, emphasis is placed on the need to screen

all TB cases and contacts for HIV, to screen all HIV positive patients for TB, and to provide Isoniazid

Preventive Treatment (IPT) to all eligible persons with HIV. With USG support, NHTC and I-TECH have

collaborated to train more than 500 government doctors and nurses on use of the new TB Guidelines. This

included TOT sessions for 38 nurses serving at the regional and national level in the "TB for nurses" course.

By the end of COP 07, this training collaboration will train 40 private practitioners in integrating TB/HIV

services in non-governmental settings.

In COP 08, I-TECH will conduct TB/HIV training courses in-person or via digital video conferencing for 75

government doctors, pharmacists and 60 private doctors; in addition I-TECH will train 40 TB program

officers from both regional and district levels as TOTs for the "TB for nurses" course. These nurse TOTs

will work with the tutors from the training network to conduct TB/HIV training for district nurses with funds

provided by the Global Fund. I-TECH will provide the training materials for the district training courses

through COP 2008 funds. All such trainings will emphasize TB screening of HIV-positive persons, HIV

testing of TB patients, and TB/HIV prevention messages.

The Integrated Management of Adult and Adolescent Illness (IMAI) program includes training in TB/HIV

primarily aimed at nurses. The WHO IMAI curriculum has been adopted in Namibia as a means of task

shifting from doctors to nurses as one strategy for addressing the severe human resources deficiencies in

Namibia that inhibit expansion and improvement of TB/HIV prevention, care and treatment services. IMAI

will be rolled out to four additional sites in COP08, as described in I-TECH's ART activity narrative; therefore

over 90 nurses will be trained on TB/HIV through the IMAI program. These nurses will be able to make

diagnosis and start TB therapy for those with positive smears.

Nurses in the private sector see many patients but often lack the necessary knowledge and skills to

recognize and manage TB according to the National Guidelines. This lack of knowledge and skills can

impede timely detection and treatment of TB, contributing to the ongoing high levels of TB transmission in

Namibia. A new activity in COP08 will be the training of private sector nurses in the management of TB and

the importance of providing HIV services and referrals to TB patients. I-TECH will conduct four courses for

a total of 80 private nurses, as requested by the National Tuberculoses Control Program (NTCP).

Additionally, I-TECH Namibia has recruited and supported experienced HIV physicians to work as Clinical

Mentors in seven of the 13 Regions in the country. Amongst other tasks, Clinical Mentors will focus on

ensuring HIV testing of all TB suspects, TB screening of all HIV clients and provision of IPT to all eligible

HIV clients in addition to ensuring that patients with TB are managed correctly and according to the new

Namibian TB guidelines. These clinical mentors have proven to be effective in ensuring consistency and

quality of TB/HIV services and referrals, as they provide day-to-day supportive supervision of clinicians.

The mentors will also support the ongoing rollout of IMAI and assist the MOHSS, TBCAP and other

stakeholders with the development of standard operating procedures to guide health care workers on

uniform and quality TB/HIV management.

Community-based DOTs is an important part of the Directly Observed Treatment Short course (DOTS)

strategy supported by the MOHSS in its efforts to combat TB/HIV. Field supervisors are stationed at

district level in six regions and there are plans for expansion to all 13 regions within the next year. They

supervise the work of TB field promoters (stationed at health facilities) who in turn manage the DOT

supporters for individual patients with TB/HIV within the community. A gap has been identified by MOHSS

whereby the field supervisors and TB field promoters have been trained by different NGOs and MOHSS

staff, resulting in incomplete and non-standardized understanding of TB/HIV management at the community

level. A new activity for I-TECH in COP 08 will be to develop standardized training materials for training the

field supervisors as TOTs, allowing them to go to the field and train the TB/HIV field promoters working in

their facilities. Training materials will include a standard curriculum as well as flip charts derived from the

training curriculum for field supervisors to use in their training. After the development of the materials, I-

TECH will then conduct two training courses to train 34 field supervisors. The field supervisors will then use

the flip charts to assist them in training field promoters on site. I-TECH will further work in collaboration with

the MOHSS and other PEPFAR partners, including PACT, DAPP, and TBCAP to support development and

integration of TB training materials into the community home based care standards.

This activity continues from COP 2007 and includes technical support for two elements: training health care

workers (HCW) in counseling and testing; and (2) provision of assistance to the community counselor

training program.

The lack of comprehensive training on HIV/AIDS prevention, care, counseling and testing and treatment for

most practicing doctors, nurses, and pharmacists in Namibia is a significant obstacle to rapid scale-up of

quality programs throughout this sparsely-populated country. Since FY04, the USG has funded the

International Training and Education Center on HIV (I-TECH) to collaborate with the Ministry of Health and

Social Services (MOHSS) to address this gap by increasing the capacity of the University of Namibia

(UNAM), the National Health Training Center (NHTC) and its five Regional Health Training Centers

(RHTCs), and the Directorate of Special Programs to train new and existing health care workers in

HIV/AIDS. I-TECH provides technical advisors, training and curriculum experts, clinical mentors,

educational and training materials, monitoring and evaluation systems for training, infrastructure, training

logistics, and funding for training. Based on new or updated national guidelines, I-TECH has facilitated the

development of the MOHSS's national training curricula on PMTCT, VCT, rapid HIV testing, Couples

Counseling, TB/HIV, ART, nutrition and HIV, IMAI, dried blood spot collection for HIV DNA-PCR for early

infant diagnosis, and pediatric care/ART. Support is also being provided to incorporate this new content into

the pre-service training curricula for registered nurses at UNAM and for enrolled nurses at NHTC. I-TECH

will play a critical role in the decentralization of HIV/AIDS care and ART through various levels of training

ranging from didactic sessions to clinical mentoring. I-TECH training activities have been central to

Namibia's success to date with meeting its prevention, care, and treatment targets and a long-term strategy

is being implemented to reach those health workers still in need of training in HIV/AIDS.

Family planning (FP) and integrated HIV prevention strategies focused on HIV-positive individuals 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 HIV/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 HIV prevention and family planning, 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, among other things. Knowledge gaps exist among

clinic staff; many HIV staff does not understand the concept of dual protection, while FP staff often believes

their clients are at low risk for HIV. I-TECH will also ensure that appropriate messages are integrated into

curricula, materials and training for MDs, RNs, and Community Counselors which promote safe sex

practices including abstinence, fidelity with condom use; family planning; support for disclosure of HIV

status; screening and support for STI care; reduction in alcohol abuse and the prevention of mother-to child

transmission of HIV.

The counseling and testing component of I-TECH's program focuses primarily on two aspects of training

and technical support: (1) direct training of health care workers (HCW) in quality counseling and testing in

partnership with the MOHSS; and (2) provision of technical assistance to the community counselor training

program which is contracted out by the MOHSS. In FY07, I-TECH trained 588 HCW in quality counseling

and testing services. This resulted in improved counseling and rapid testing services offered in medical

settings (an emphasis area in COP2007 and COP2008) by health care workers. I-TECH also provided

technical assistance to the MOHSS Community Counselor and Rapid Testing Training Coordinators who

are recruited and supported through Potentia to expand quality counseling and testing services offered by

community counselors in MOHSS facilities.

In COP2007, I-TECH supported the MOHSS and partners with the revision of the National Counseling and

Testing Guidelines of the MOHSS and development of a curriculum on provider initiated counseling and

testing (PICT). I-TECH also began integration of family planning and HIV prevention messages into the

patient education flipchart adapted for the IMAI trainings. The Couples Counseling curriculum has since

been reviewed in line with the national CT guidelines. Couples Counseling training addresses the issues of

male norms and behaviors, including the unique needs of serodiscordant couples and negative outcomes

that particularly women may face in disclosing HIV-positive status. It also addresses the issue of stigma and

discrimination by requiring HCWs to develop empathy for patients through counseling role plays. This is

also meant to address the challenges faced by HCWs in dealing with HIV in their own lives and in their

families. Counseling children infected and affected by HIV remains a challenge for the health workers as

there is no guiding information in the current counseling curricula.

In COP2008, I-TECH's emphasis areas in CT will include continued training and technical assistance, local

organization capacity building and human resources. In COP08, funding covers:

1) A total of 250 additional health workers will be trained in rapid HIV testing using the curriculum developed

with USG support. This relates to Potentia, MOHSS and NIP.

2) One TOT in Counseling and Testing and 10 subsequent in-service trainings to train a total of 240 health

workers in both VCT and Provider Initiated Counseling and Testing in clinical settings. These trainings will

be conducted by 10 in-service tutors supported by Potentia at NHTC. The VCT curriculum will also be

revised in accordance with the new MOHSS guidelines in counseling and testing.

3) One TOT in Couples Counseling and 10 subsequent in-service trainings to train a total of 240 health

workers. These trainings will be conducted by 10 in-service tutors supported by Potentia at NHTC.

4) 50 site visits conducted by the in-service tutors to health care facilities providing CT services, to assess

transfer of learning and to provide additional on-site teaching.

5) Development and delivery of training on Prevention with Positives in partnership with CDC-Atlanta. One

TOT and five regional trainings will be held to train a total of 125 health workers to ensure national rollout of

PwP.

6) Development and integration of a module on the counseling of infected and affected children in the

existing counseling modules.

Activity Narrative: 7) I-TECH will continue to support the revision of guidelines and curricula in COP08.

8) Delivery of training on HIV and Monitoring and Evaluation for the HCWs. Five regional trainings to be

held to train 125 HCWs in monitoring and evaluation.

In a new and related initiative funded through HVOP, I-TECH will train 34 new case managers who will be

based in ART clinics and ANC sites. These case managers will carry out a variety of functions, including

adherence counseling, defaulter tracing, linking clients to community-based health and social services, and

facilitating support groups. I-TECH will train these case managers on these functions, and as it relates to

this activity, on assisting and coaching HIV-positive persons in notifying their exposed partners and referring

them for CT services.

All programming funded through this activity will incorporate gender messaging in compliance with

Namibia's male norms initiative which seeks to address cultural norms that factor into HIV transmission,

including lack of health care seeking behavior by men, multiple sex partners, transactional and

transgenerational sex, power inequities between men and women, and heavy alcohol use.

Capacity building of doctors, nurses and pharmacists in ART is an essential component to providing quality

management of patients with HIV and it forms part of the package offered by the International Training and

Education Center on HIV (I-TECH) in collaboration with the Ministry of Health and Social Services (MOHSS)

and funded by the USG. To date I-TECH has trained more than 6,300 health care workers (HCWs) in

various HIV and AIDS topics. This number includes nearly 2,000 physicians, pharmacists and nurses

trained in ART, comprehensive pediatric HIV care, tuberculosis (TB) and other opportunistic infections

(OIs), and integrated management of adult and adolescent illnesses (IMAI).

I-TECH provides in and pre-service training on HIV and AIDS for HCWs both in private and public settings.

It also provides MoHSS with curriculum and training material development experts and with development of

monitoring and evaluation systems for training in Namibia. In addition, I-TECH provides MOHSS with

technical advisors and clinical mentors (CMs) to provide on-site capacity building and quality improvement

for ART care through supportive supervision.

With FY 2007 funds, I-TECH supported four experienced HIV physicians as CMs in the major ART sites in

four regions (Khomas, Otjozondjupa, Oshana, Kavango). These CMs also provide mentorship in

Ohangwena, Caprivi and Omusati ART sites. Furthermore, in collaboration with MoHSS and the USG team,

I-TECH will second an additional fifth CM for Ohangwena region, the home to 12.5% of Namibia's

population with an HIV prevalence rate of 27% and > 3200 HIV patients on ARVs.

CMs provide on-site clinical supervision and mentoring to ART sites by reviewing challenging cases with

local doctors and identifying aspects of the guidelines which are not operationalized by the local ART

doctors and then ensuring appropriate guideline utilization and follow-up. To ensure skills transfer and

sustainability, CMs train recently qualified Namibian doctors to become ART providers; CMs also assess

training needs, and routinely provide didactic and hands-on training to address knowledge and skills gaps.

CMs assess clinics to establish systems including rational patient flow to reduce patient waiting time. They

also promote a multi-disciplinary approach to HIV care, and support ART pharmacists and nurses in their

provision of ART services. One recent achievement of the CM program is the systematic implementation of

Isoniazid Preventive Therapy (IPT) for eligible patients within the ART clinics, which resulted in > 2500 HIV-

positive persons starting IPT for TB.

In FY 2008 the CM programme will continue serving the initial seven regions. CMs will continue to assist in

HIV-related national physician training and to contribute to the development and revision of HIV-related

guidelines and training manuals. Moreover, as per MoHSS request, a sixth clinical mentor will be recruited

and deployed in Karas Region's major ART site, supporting ART sites in all its districts. Karas Region has a

population of 69,329 and an HIV prevalence rate of 23%.

To increase ART training capacity of local physicians, I-TECH will hold one Physician TOT course for 14

doctors with FY 2007 funds. This activity will continue in FY 2008 with two Physician TOT courses, one for

14 state doctors and one for 14 private doctors.

With FY 2007 funds, I-TECH also updated the ART curriculum to be in line with the new guidelines. I-TECH

will have carried out four ART in-service training courses, training 150 government physicians by the end of

FY 2007. With FY 2008 funds I-TECH will conduct four 4-day ART courses for 120 government physicians

and pharmacists, and will also develop a curriculum for two-day advanced refresher course for government

doctors and pharmacists who have already taken the basic course. This curriculum will be operationalized

by conducting 2 refresher courses, each for 20 physicians and/or pharmacists.

Many working Namibians belong to medical aid funds and some receive ART care from private doctors.

The regulation of the ART prescribing practices of private doctors is not yet well-established in Namibia. In

addition, private pharmacists often lack the appropriate training and knowledge to advise private doctors in

order to ensure appropriate ARV provision in line with the national guidelines. To overcome this challenge

and to ensure quality and unified ART service provision in both public and private settings, I-TECH has

provided training to 112 private doctors and pharmacists in collaboration with the Namibia HIV Clinicians'

Society. With FY 2008 funds, I-TECH will, in collaboration with the MoHSS and the HIV Clinicians Society,

develop a basic ART training curriculum with pre- and post- test assessments targeting private doctors and

will train 60 private doctors using this curriculum. I-TECH will further develop an advanced ART course for

private doctors and this course will be given to 40 private doctors and pharmacists. I-TECH will collaborate

with a USG funded partner (Capacity Project) to implement this activity

Program data at the end of March 2007 showed that 13% (ART-HIS) of patients on ART were children. A

variation between sites exists; in some only 3% of patients on ART were children. Anecdotal reports from

different sites suggested that some doctors were not comfortable treating children with ART. Thus there is

a need to train more health workers on this subject. With FY 2007 funds, in collaboration with local pediatric

experts I-TECH has developed a comprehensive pediatric HIV care curriculum; so far 71 doctors have been

trained. With FY 2008 funds I-TECH will conduct four pediatric HIV care courses for 75 government

doctors. I-TECH will develop a curriculum targeting private doctors and 25 private doctors will receive this

training. In addition, I-TECH's clinical team will provide supportive supervision for the newly trained doctors

with on-site technical assistance. Furthermore, where extra orientation and training is needed, doctors will

be offered one-week clinical attachments to a well-functioning pediatric unit.

With FY07 funds I-TECH adapted the World Health Organization (WHO) IMAI generic guidelines, training

manuals and information education and communication (IEC) materials to support the MoHSS to expand

the decentralization of ART services. The IMAI program supports the delivery of ART within the context of

primary health care, based at first level health facilities. This strategy entails task shifting from specialized

to less specialized health care workers; from doctors to nurses and from nurses to community counselors.

Thus far I-TECH has trained 24 district managers, 20 TOTs, 32 service providers and 13 expert patient

trainers (PLWHA who are on HAART, and trained to portray patients with HIV in role plays, and give

feedback to health workers on their skills) all of whom will be deployed within four pilot health facilities in

four regions.

With FY 2008 funds I-TECH will conduct eight IMAI regional training courses for 125 HCWs. In addition, I-

TECH recruited an IMAI nurse mentor who will provide technical assistance for IMAI implementing sites and

four additional IMAI nurse mentors will be recruited and deployed in the roll-out sites in FY 2008.

Furthermore, I-TECH will integrate IMAI content within National Health Training Center and University of

Namibia pre-service curricula.

Patient adherence to treatment is known to be the most important factor determining the clinical outcome of

ART. With COP07 funds, I-TECH supported an update of the adherence counseling curriculum as well as

conducted one TOT and five regional training courses, training a total of 120 HCWs. In FY08 I-TECH will

continue to provide support to MoHSS in Adherence Counseling, covering the costs of ongoing review of

the curriculum and one TOT plus 5 regional trainings for 145 HCWs.

Activity Narrative:

Namibia Institute of Pathology (NIP) is a parastatal institution that provides laboratory services mainly to the

public, and to a lesser extent the private sector, both on a commercial basis. Having a nationwide network

of 34 laboratories and employing approximately 270, its functions include: performing routine diagnostic

tests; assisting in the necessary national screening and surveillance of various diseases, including a

biannual HIV sero prevalence study among pregnant women which is conducted in conjunction with the

Ministry of Health and Social Services (MoHSS); monitoring ARV treatment effectiveness such as

therapeutic drug monitoring; and in the not so distant future, monitoring of HIV drug resistance. NIP is also

responsible for providing practical training to medical technology students and interns; conducting

operational research applicable to Namibia's health care system and advising the MOHSS accordingly.

Currently, over 70% of work conducted at NIP is dedicated to the public sector.

The mounting challenges of the HIV epidemic and TB have resulted in a dramatic increase in the use of NIP

services over the past few years. To support the MoHSS plan for scaling up of treatment and care, the NIP

has introduced more specialized and complicated procedures which include new testing methodologies and

automation. These changes have necessitated skills improvement and expansion in staff in order to

manage the ever-changing work environment.

To enhance the capacity of the training unit and thereby support the national care and treatment scale up, in

FY06 and 07 I-TECH with support from USG through CDC, assisted NIP to establish a training unit. In

addition, I-TECH procured computer and training-related equipment and is currently renovating and

upgrading the training facility within the NIP. Furthermore with the FY07 funds, I-TECH is assisting NIP to

develop training curricula to begin in-service training.

To ensure that the training unit's capacity is enhanced in order to meet the demands of training provision

within NIP laboratories, I-TECH will renovate and upgrade lecture rooms and procure additional training

materials.

In collaboration with International Laboratory Branch Consortium partners, I-TECH will assist NIP to review

and update the current training curricula and will assist the NIP training unit to conduct 10 in-service training

courses for 150 laboratory personnel in FY08. I-TECH will coordinate travel, venue, accommodations,

meals, material production and other logistics for the training while technical instruction and facilitation will

be conducted in collaboration between I-TECH and CDC.

MOHSS/DSP Response Monitoring and Evaluation is tasked through MTP-III to monitor the overall

effectiveness of MTP-III strategies and collect the necessary data from different stakeholders to report on a

regular basis on the implementation of the response to HIV and AIDS. The sub division RM & E has

developed a strategic M & E plan and the purpose of the plan is to guide the country's response with

essential information on the core indictors that measure the effectiveness of the national response to

HIV/AIDS. However, inadequate human resources, insufficient funding and technical capacity are the major

constraints which restrict the country's development of a cohesive and effective national M & E system.

There is one overall M & E database that has been developed to capture the indicators as required by MTP-

III in 2003 but the system is not yet operational.

The emphasis for this activity will be to conduct training to support the Monitoring and Evaluation (M+E) Unit

of the National AIDS Programme and the National Health Information System (HIS) Unit in building capacity

for the collection, analysis, and reporting of surveillance and routine health information related to HIV/AIDS.

Training workshops will build capacity in personnel working directly or indirectly for the MoHSS to collect,

summarize, analyze, and disseminate HIV/AIDS, TB and STI strategic information and thus advance the

USG priority to use SI for program and policy improvement. It will leverage USG-supported technical

advisors (, equipment provided by USG, and personnel provided to the MoHSS with PEPFAR and Global

Fund support. This activity relates to a variety of other activities focussed on data quality and use (7361,

7374, 7365, 7361, 7365, 7355, 7355, 7328, 7377, 7374).

To support these efforts, the USG will use the expertise of I-TECH, which has been supporting the MoHSS

to train healthcare workers in skills and theory related to HIV/AIDS since 2003. I-TECH in collaboration with

CDC will coordinate training workshops on data collection and processing for those responsible for

M+E/HIS around the country. I-TECH will coordinate travel, venue, accommodations, meals, material

production and other logistics for the workshops listed below while technical instruction and facilitation will

be the responsibility of topic-area specialists. In addition, to strengthen the M&E capacity and ensure

quality of data collection, analysis and dissemination of government partners including University of Namibia

(UNAM) and National Health Training Centers (NHTC) I-TECH will recruit a senior M&E coordinator with

FY08 funds.

1. Training workshops in various health sector tools: This is a continuation activity from FY04-FY07. USG

will support 8 central training workshops for data clerks and HIS officers to build their data entry,

management, and reporting capacity so that they will be proficient in using the Ministry's management

information systems for ART/PMTCT/VCT/TB/STI. Selected participants of these workshops will also

receive Training of Trainers (TOT) so they can give workshops in the regions where they work.

2. Training workshops in Monitoring and Evaluation (M+E): This sub-activity is a continuation from FY07.

USG will support 1 training workshop for MoHSS personnel and selected partners to build their capacity in

the theory and practice of monitoring and evaluation of HIV/AIDS programs. Through this activity, 30

persons will be trained from MoHSS and key partner organizations. I-TECH will provide travel,

accommodations, and meals for participants as well as the meeting facilitators.

3. Training workshops in health information systems: This sub-activity is a continuation from FY07. USG will

support 12 regional workshops to build capacity in the electronic Namibian routine health information

system (the District Health Information System or DHIS). Each regional training workshop will last 5 days

and will accommodate 20 participants. Regional training workshops will include 3 in Tsumeb, 3 in

Otjiwarongo, 3 in Windhoek, 1 in Oshakati, 1 in Rundu, and 1 in Swakopmund. These training courses will

build capacity in health information systems officers to use the National electronic system.

4. Training workshops in STI surveillance: This sub-activity is new in FY08. USG will support 26 regional

training workshops to build capacity in using the revised WHO system for STI surveillance. Each training will

last 2 days and will be attended by 5 participants who will participate in this surveillance system at the

regional and district levels.

5. Workshop to develop an advocacy and communication plan: In order to have its intended effect, strategic

information must be appropriately communicated to the appropriate audience. The appropriate

communication methods and channels must be identified and leveraged to disseminate this valuable

information. This activity will sponsor a 1-week workshop on advocacy and communication of M&E

information.

6. Disseminate findings from the 2008 sentinel survey for HIV in pregnant women: HIV prevalence results

from the sentinel HIV survey in pregnant women are often quoted but frequently mis-understood. This

activity will support workshops in each of the 13 Namibian regions at which sentinel survey results will be

disseminated and discussed.

7. Workshops to support development (for new) and review (for existing) M&E frameworks and plans:

Monitoring and evaluation of the HIV/AIDS/TB response is guided by nationally approved guidelines and a

framework to organize implementation of these guidelines. Though the national guidelines provide broad

M&E direction, it is critical that sub-national (regional and organizational) M&E plans be developed and

implemented. This activity will support workshops to review the national M&E plan and to develop and

implement regional and institutional M&E plans.

8. Training in monitoring and evaluation: This activity will support training activities in monitoring and

evaluation of program implementers and programme managers. A monitoring and evaluation curriculum for

the country has been developed based on international standards and with assistance from a Regional

M&E expert. This activity will support training of target personnel from government and non-government

organizations in this curriculum. M&E tools will be covered in these training workshops.

This activity is a continuation of FY07 and supports two components: (1) HIV integration into training for

nurses, and (2) Strengthening of human resources management systems.

(1) The lack of comprehensive training on HIV/AIDS prevention, care, and treatment for most practicing

doctors, nurses, and pharmacists in Namibia is a significant obstacle to rapid scale-up of quality programs

throughout this sparsely-populated country. Since FY04, the USG has funded the International Training and

Education Center on HIV (I-TECH) to collaborate with the Ministry of Health and Social Services (MOHSS)

to address this gap by increasing the capacity of the University of Namibia (UNAM), the National Health

Training Center (NHTC) and its five Regional Health Training Centers (RHTCs), and the Directorate of

Special Programmes (DSP) to train new and existing health care workers (HCWs) in HIV/AIDS, including

pediatric care and treatment. I-TECH provides technical advisors, training and curriculum experts, and pre-

in service tutors for these institutes.

Through support from the USG, I-TECH provided technical assistance to integrate HIV content into both the

existing four-year pre-service Diploma Nursing Course and the Advanced Diploma Course in Health

Promotion, Clinical Diagnosis and Treatment and Pharmacotherapy in FY07. I-TECH then oriented over 20

UNAM lecturers on the revised curricula. It is anticipated that the revised and integrated curriculum which is

designed to equip student nurses with a broad base of specialized knowledge and skills will enhance the

production of more knowledgeable and skilled professional nurses in HIV/AIDS/TB care. It is also

anticipated that more HIV-infected patients will receive quality HIV/AIDS care and HIV transmission

resulting from unsafe medical practices will be significantly reduced. To ensure the training is put into, I-

TECH recruited and deployed via Potentia (7341) three Nursing Lecturers and four part-time Clinical

Instructors at UNAM campuses in Windhoek and Oshakati to provide follow up training for students at their

clinical sites. UNAM has increased its intake of nursing students in response to the severe shortage and

continues to need support in facilitating the classroom and clinical component of the training. To better

meet the needs in FY08, I-TECH will increase the part-time lecturer position to full time and will recruit and

deploy two additional nurse lecturers via Potentia with FY08 funds. In addition, I-TECH will continue

incorporating and finalizing the curricula and will conduct three orientation workshops at UNAM.

Furthermore, to enhance the quality of pre-service training, I-TECH will procure additional training materials

and equipment.

Namibia, as a result of its apartheid past, has limited human capacity, both in quantity and availability of

particular skills. The limitation in human capacity transcends all levels of health services delivery, from the

national management level with limited capacity to provide the necessary technical support, stewardship,

coordination and monitoring of services. The regional and district levels fall short in providing decentralized

management, training and support, and the health facility level often is not able to cope with the burden of

service provision and community support.

(2) Human resource challenges facing the health sector include staff shortages and high vacancy rates;

staff turnover; lack of sufficient training institutions and programs; lack of financial resources to increase

production of human resources; inability to attract sufficient number of prospective students; and multi-year

training programs which making human resources capacity development a slow process. These challenges

are more acute in the public health sector, and are further exacerbated by the HIV/AIDS pandemic and its

demands on available human resources. The Namibian private sector is able to successfully secure most

of the available health care workers, especially those that are Namibian. The private sector is a major

partner in the provision of treatment, care and support to HIV infected patients, catering for approximately

6,000 patients on ART. In FY07, over 200 registered nurses, enrolled nurses, and physicians left the public

sector for the private sector.

To ensure successful implementation of the programs addressing HIV/AIDS challenges, PEPFAR has

funded I-TECH to support the MOHSS to strengthen its human resource management system by reviewing

and developing the necessary policies and regulatory frameworks that will support the implementation and

roll out of prevention, care and treatment programs. The implementation of these programs at the peripheral

health facilities requires specific clinical skills and prescribing that are not regularly available, especially

among nurses who are the major providers of services at both the health center and clinic levels. The

introduction of new tasks as part of the scope of practice requires considerable training (pre-service and in-

service), policies and possible legislative changes, revision of existing training programs and curricula to

ensure that a greater number of future health care workers are well prepared before they enter the health

system is crucial . In this regard I-TECH has been supporting UNAM as well as the NHTC to strengthen its

capacity in reviewing curricula and strengthening capacity of the teaching personnel and deploying pre-in

service tutors.

With FY07 funds, I-TECH recruited and deployed Human Resource Technical Advisor (HRTA) within the

Human Resource Development Division (HRDD) in the MOHSS. The HRTA role is to support HRDD to

develop an essential services package (ESP) to implement at district health level, with focus on district

hospitals, health centers, clinics, and community-based health care, including outreach services. The ESP

has been developed through consultations with key stakeholders at national, regional and district levels.

The ESP clearly defines the type of services to be provided at various levels and the resources necessary

to provide them. The ESP provides a framework to determine tasks and competencies that are required for

the continued rollout of HIV prevention, care and treatment services.