This is an ongoing activity from COP2007 and supports the care component of the Namibian Ministry of

Defense's HIV/AIDS Military Action and Prevention Program (MAPP). The activity is focused on providing

basic elements of clinical care, community and home-based care, psychosocial care and stigma reduction

to military members living with HIV, as well as for any military family members who are HIV-positive.

Clinical palliative care will be provided to HIV positive military members and their immediate family

members who are also HIV-positive at the two Namibian military hospital ART sites in Windhoek and in

Grootfontein. Services include prevention and treatment of OIs (including provision of cotrimoxizole

prophylaxis), provision of isoniazid preventive therapy (INH) for eligible clients, screening and care for

sexually transmitted infections (STIs), and screening and alleviation of HIV-related symptoms and pain. It is

estimated that in COP 2008 up to 1900 clients will be given cotrimoxazole prophylaxis; this number includes

the 1600 patients on ARVs and an estimated further 300 who will be eligible for cotrimoxazole but not yet

for receiving ARVs. An estimated 500 HIV-positive clients will be treated with INH in COP2008. To support

technical implementation of clinical care, fifty Ministry of Defense health care workers will be trained in

proper prophylaxis and management of OIs including tuberculosis. Adherence to antiretroviral therapy

(ART) is regarded as the most important factor affecting success of antiretroviral treatment. In order to

improve health provider support for effective ARV adherence, I-TECH will provide training in adherence

counseling for 40 military health workers from the two ART sites and at least three sickbays.

I-TECH, in collaboration with the MoHSS nutrition division and the ITECH nutrition program, will offer a

routine nutritional assessment, counseling and monitoring of nutritional status at the two ART sites, with

provision of short-term therapeutic feeding for clinically malnourished patients according to the MoHSS

entry and exit criteria. It is currently estimated that 300 (20%) of clients will require short-term nutritional

support. All patients registered at the ART clinic will receive routine daily micronutrient supplementation.

I-TECH will support 30 outreach nurses from the two ART sites and other sickbays to provide home-based

palliative care for chronically and terminally ill military and family members who require home support. Each

outreach nurse will receive training and technical support in community and home-based palliative care

(CHBC), as well as receive the standardized home based care kit which is recommended by the MoHSS to

enable them to carry out more effective and quality homecare visits. Services provided by in the home will

include physical care (wound care, cleaning, bathing), psychological care and symptom screening, relief

and referrals to the nearby facility for additional services. It is anticipated that a minimum of 60 patients

living with HIV may need home visits in COP 2008. I-TECH will also provide training and technical support

to health care providers at Oshakati military base so they may scale up their home based palliative care

program in the north-west of Namibia, which currently have more than 100 soldiers placed on home-based

palliative care. In COP2008, the USG will explore opportunities to partner ITECH with the African Palliative

Care Association in order to strengthen the palliation care skills of the nurses in the overall Ministry of

Defense care program.

This initiative will also integrate referrals and linkages to care services withing the MAPP prevention

program. ITECH will partner with the MAPP program, improve awareness of basic care services and

integrate referrals for psychosocial, spiritual and social support for military members living with HIV. The

program will support the establishment of an HIV support group of HIV positive military members at the two

military ART sites.

In order to tackle stigma and discrimination within health system, I-TECH will collaborate with a local non-

governmental organization in the military catchment areas to conduct a 3-day workshop on a program

called ‘HIV and me' for 46 military health workers. This workshop is facilitated by people living with HIV and

aims to assist health workers to confront actions associated with stigma and discrimination against HIV-

positive patients.

At all levels, attention will be given to increasing the gender equity in accessing HIV and AIDS programs. I-

TECH will ensure equitable access to services for both men and women, encouraging the participation of

men and boys and their responsibility in care giving and support for female caregivers, as well as

addressing stigma and discrimination.

This activity continues from COP2007 and includes 2 elements: direct counseling and testing services in the

Namibian military; and (2) training, technical support and supervision to improve quality of counseling and

testing services. This program will continue to support the Ministry of Defense's Military Action and

Prevention Program (MAPP) by providing military community counseling and testing at the existing 2

military counseling and testing centers in Grootfontein and Rundu, two new military counseling and testing

centers at the Osona Military School and Walvis Bay Naval Base (established under COP07), the military

hospitals in Grootfontein and Rundu and expansion of two new VCT centers which will be opened at two

additional military bases (sites TBD). The slow implementation of the program did not allow for the use of

mobile CT services in the military during COP07. Therefore this activity will be implemented during COP08

to ensure mobile coverage to all military bases/camps. Each of the four military CT will be manned by a

trained site manager, two counselors, a receptionist and a nurse. These personnel will continue to receive

training and refresher courses in order to further enhance their CT skills and to continue to implement the

CT program in line with the Ministry of Health and Social Services National Guidelines for Counseling and

Testing. The USG will also strengthen the institutional capacity of the Ministry of Defense within the MAPP

program to manage the CT program to ensure long term sustainability. COP08 funds will support intense

activities to ensure that the number of soldiers, who have been counseled, tested and received their test

results for HIV increases from the targeted 7500 in COP07 to 9000 in COP08. The Program strives to do a

100% testing in the military subject to the concurrence of the Ministry of Defense/Namibian Defense Force

(MOD/NDF). The program supports both a VCT approach and a provider-initiated counseling and testing

approach. The program will provide pre-test counseling services, testing with rapid test kits, post-test

counseling for both HIV negative and HIV positive clients, and referral to the new military care and

treatment program for those members that test positive. Messaging on prevention with positives and basic

care will be integrated in the program, including safe sex practices such as abstinence, fidelity with condom

use; family planning; male involvement; support for disclosure of HIV status; screening and support for STI

care; reduction in alcohol abuse; the prevention of mother-to child transmission of HIV; and basic preventive

care actions such as prophylaxis for OIs, good nutritional and hygiene practices, screening for TB, etc. A

total number of 46 military counselors were trained under COP07. COP08 funds will be used to train an

additional number of military HIV/AIDS counselors in order to build the capacity for counseling and testing

services at all the 23 bases/camps. Training in CT will include leadership and supervision training for site

managers, couple counseling, prevention with positives, alcohol and STI basic counseling, and gender

based violence and empowering women and data management for the counselors. The CT database used

to capture data by SMA during COP07 has been moved to the MOD/NDF and 2 MOD/NDF data clerks have

been trained data capturing and management. Close linkages will be kept with the MAPP care and

treatment partner in capturing data related to counseling and testing, and training the MOD/NDF data clerks

to ensure that counseling and testing data is recorded in the military health management and information

system. A MOD/NDF laboratory technologist will be trained in the analysis of tests through the National

Institute of Pathology (NIP). The prevention partner will work very closely with the Supply Chain

Management Systems (SCMS) in procuring test kits and other medical consumables for the military

counseling and testing services. Detailed logistics on how these test kits will be distributed to the military

bases/camps will be worked out between the MOD/NDF, the prevention partner and SCMS. Establishing

performance benchmarks will be the key in maintaining quality of CT services. The existing quality

assurance tools will be reviewed with MOD/NDF in collaboration with Ministry of Health and Social Services

(MoHSS) to establish relevance and appropriateness to both the static and outreach services. Parameters

for performance will be defined to include quality of services, number of soldiers reached and effective

referral linkages. This activity will strive to include Quality Assurance for CT in close collaboration with the

MoHSS and the Namibia Institute of Pathology (NIP). Rapid Test Quality assurance will be managed by the

MOD laboratory technologist with the support of the NIP. Information leaflets, brochures and flyers,

including information on alcohol, gender based violence and male norms, messaging on safe sex practices

including abstinence, fidelity with condom use; family planning; male involvement; support for disclosure of

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

transmission of HIV; and basic preventive care actions such as prophylaxis for OIs, good nutritional and

hygiene practices, screening for TB, etc will be distributed in CT waiting rooms. Some of these materials will

be translated into one or two local languages in order to ensure that military members who may not be

fluent in English also benefit from prevention messages.

FY 2008 funding will support the scaling up of HIV and AIDS treatment within the Namibian Ministry of

Defense/ Namibian Defense Force (MOD/NDF). According to studies conducted in other countries,

indicated that the HIV prevalence rate in the military is higher than the national average. The 2006 antenatal

sentinel survey showed a prevalence rate of 19.9% in Namibia. There are estimated 14,000 -15,000

personnel in the MOD/NDF and inline with the national prevalence rate assumptions are that there are

about 3,000 HIV-positive military members. Through FY 2008 funds, I-TECH in collaboration with the

Military Action & Prevention Program (MAPP) prevention partner will support the MOD/NDF to conduct a

HIV sero-prevalence survey in order to confirm the estimated prevalence rate among military personnel.

With FY 2007 funds, one ARV treatment center has been identified in Windhoek and is being renovated.

With the FY 2008 funds an additional ARV center will be established and renovated in Gootfontein army

hospital. In order to ensure appropriate and quality care and treatment services within the military health

facilities, the Ministry of Health and Social Services (MOHSS) ART guidelines will be followed in all aspects,

including ART initiation and patient follow up. To ensure that HIV positive military personnel and/or their

family members have access to sustainable quality care and treatment services, HIV-positive personnel

who were referred to the MOHSS communicable disease clinics for ART, will be referred back to the

MOD/NDF medical services. With FY 2008 funds, I-TECH will build the capacity of surrounding military

sickbay facilities to promote effective HIV-positive patient referral systems. It is expected that 1600 military

personnel, including their family members, will be on ART by the end of FY 2008.

The military has a shortage of medical doctors, and has addressed this in the long term by sponsoring some

students in medical training. This program will bridge the gap and hire a minimum of two full time doctors to

directly support the ARV treatment program, one working in each military hospital. There are approximately

120 nurses and pharmaceutical staff in various health facilities in the MOD/NDF as well as four laboratory

technicians who are currently practicing at the Namibia Institute of Pathology (NIP). In order to ensure

sustainable capacity building within the military health services I-TECH will train and utilize the existing

military personnel in the provision of ART services including, patient management, adherence counseling,

pharmaceutical, laboratory, data entry, and analysis services at care and treatment sites within the military

hospitals. This approach allows the military to maintain their confidentiality requirements and also ensures

sustainability of the program.

Thus far I-TECH has trained 27 MOD/NDF health workers, selected from 23 military sickbays, in ART and

opportunistic infections including tuberculosis during FY 2007. An additional 45 healthcare workers from the

military will be trained in these areas including adherence counseling in FY 2007.

To continue with capacity building, 50 MOD/NDF health care workers from the 23 military camps/bases will

be trained in different HIV-related areas including the provision and management of ART, adherence

counseling, couples counseling, prevention with positives, PMTCT, and the newly introduced Integrated

Management of Adult and Adolescent Illnesses (IMAI) with FY 2008 funds. In addition, I-TECH in close

collaboration with the MOD/NDF will continue to build the capacity of military personnel to ensure

appropriate program monitoring and evaluation, by training military health care workers to monitor and

evaluate the program activities. Further collaboration with the MOHSS in the area of M&E will be

maintained in order to ensure integration of the military ART M&E program with the national health

information system.

Adherence is the most important determiner of response to ART. In addition to strengthening adherence

counseling, I-TECH will sensitise health care workers at all 23 military sickbays on the important role of

treatment supporters. Tracking of clients who miss appointments will be enhanced through strengthening of

linkages with the treatment supporters. Furthermore, to track clients who are due for follow-up, I-TECH will

sensitize health care workers to utilise the Health Management Information System (HMIS).

Three MOD/NDF health care workers and the I-TECH project coordinator will attend the US Department of

Defense HIV/AIDS Prevention Program (DHAPP) annual training specifically targeted for the military in

either Uganda or San Diego to ensure that the particular needs and challenges of the military are taken into

account.

The number of female soldiers in the MOD/NDF is limited and delivery services are not available within

military health care facilities. As a consequence, I-TECH will maintain a referral system with the public

hospitals for pregnant soldiers.

In order to increase the uptake of ART services within military settings, I-TECH will develop military specific

information, education and communication (IEC) materials (leaflets, flyers, brochures) and possibly translate

some in local languages. This will further be enhanced through a close collaboration with the MAPP

prevention partner by ensuring that IEC materials are disseminated to all military counseling and testing

centers. Materials will include information on condom availability at all health facilities, family planning,

prevention with positives, alcohol abuse, and adherence to medication, living positively with HIV, nutritional

issues, and addressing gender issues. In collaboration with the MAPP prevention partner, I-TECH will

continue to promote the messages of faithfulness and proper and consistent use of condoms, especially

amongst military members who have tested positive.

.

In line with the national ART guidelines, standard operating procedures for clinical care and treatment of

HIV-infected adults and children will be established including procedures for identifying HIV-exposed and at-

risk children, providing cotrimoxazole and isoniazid for all eligible HIV-infected persons, ensuring linkages

across programmatic areas, promoting adherence and rapidly identifying those lost to follow-up, providing

laboratory services, monitoring and evaluation, including on-site supervision, and managing drug and health

commodities.

In order to ensure linkage of nutrition into ART care, as part of the basic palliative care activities I-TECH will

assess the dietary and nutritional requirements of the HIV-positive military personnel on ART and provide

support in close collaboration with the MOD/NDF.

Close linkages will be kept with the MOHSS and NIP to ensure that the program is being implemented

within the framework of national policies and guidelines. At all levels, efforts will be made to ensure close

linkages with the MAPP prevention program.

Activity Narrative:

This program will be managed by the Defense Attaché Office (DAO) PEPFAR Program Manager through I-

TECH-Namibia; an experienced HIV/AIDS contractor based at the University of Washington (UW) Center

for AIDS and STD (a WHO collaborating center) and is a collaborative effort between the UW and the

University of California San Francisco.

At all levels attention will be given to increasing the gender equity in accessing HIV and AIDS programs and

addressing stigma and discrimination.

As an expansion of the Military Action and Prevention Program (MAPP), the Ministry of Defense/ Namibian

Defense Force (MOD/NDF) has initiated a new HIV/AIDS care and treatment program for its military

personnel under FY 2006. Laboratory support is essential for implementation of an ART program in the

military. Currently, the MOD/NDF uses the laboratory facilities of the National Institute of Pathology (NIP)

for testing purposes. Emphasizing the unique nature of the military and the issue of confidentiality of data,

the MOD/NDF has expressed the need to establish their own laboratory facilities within the military hospitals

where ART services will be provided. I-TECH will work very closely with the MOD/NDF and the NIP to

establish these laboratory facilities.

It is estimated that by the end of the reporting period a total number of 1600 military members will be

receiving ART within the military settings during FY 2008. Laboratory services will therefore cater for

patient evaluation before initiation of ART, monitoring the clients on ART and the counseling and testing

services. The MOD/NDF has so far trained four laboratory technicians who are seconded to NIP while the

MOD/NDF laboratory facilities are being established. Once the laboratory facilities have been established at

the two ART sites, these four technicians will be expected to work at those two facilities. I-TECH will also

facilitate the training of at least six military laboratory personnel through NIP in order to ensure appropriate

use of the new equipment and provision of quality services and sustainability of services at the military

facilities. As the ART services expand, further training needs assessment in this important program area will

be conducted so that additional military personnel can be trained to ensure sustainability.

The MOD/NDF will continue to collaborate with the NIP in identifying and selecting critical members to be

trained as laboratory technicians in order to ensure the suitability of services in the MOD/NDF facilities. In

addition, the MOD/NDF will also continue to seek the support of NIP in terms of quality assurance of the

services provided in the military laboratory facilities.

CD4 testing is an important tool for determining clinical eligibility for HAART and coupled with other basic

laboratory tests for monitoring HIV-disease. The Ministry of Defense (MOD/NDF) has indicated that it

essential to perform CD4 testing as well as other basic monitoring tests within military laboratories in order

to ensure effective and sustainable ART service provision within the military health delivery system.

CD4 tests are currently being sent to NIP. Due to increased referrals from the military counseling and

testing services and the need to regularly monitor patients on HAART, it is anticipated that the requests for

CD4 counts will increase markedly in the short term. NIP not only provides these essential services to

MOD/NDF but NIP also provides such services to the Ministry of Health and Social Services and other ART

service providers, which sometimes delays the return of results to clients such as MOD/NDF.

I-TECH will collaborate with Supply Chain Management Systems (SCMS) in the procurement of equipment

and pharmaceuticals for the MOD/NDF ART facilities. Logistics for the procurement of pharmaceuticals will

be discussed in details between the MOD/NDF, I-TECH and SCMS. I-TECH will support MOD/NDF to

renovate and upgrade the current laboratory services.

The Defense Attaché Office (DAO) PEPFAR program manager will manage this program and administer

funding through I-TECH Namibia.

In FY 2008, the USG Department of Defense (DOD) will continue to strengthen the Namibia Ministry of

Defense/Namibian Defense Force (MOD/NDF) monitoring and evaluation (M&E) system by drawing on the

experience and expertise of I-TECH. An advanced training program will be organized for five M&E

personnel in the MOD/NDF who received basic M&E training in FY 2007. This training may be held at the

Polytechnic of Namibia or in South Africa. The purpose is to ensure that care and treatment program patient

data will be accurately collected and analyzed, integrated into the overall MOD/NDF Health Management

Information System (HMIS), and used for patient management (e.g. to identify defaulters early) and for

planning. The MOD/NDF M&E system will be enhanced with additional necessary equipment in FY 2008.

I-TECH will closely collaborate with the Military Action and Prevention Program (MAPP) prevention partner

in capturing data from all MAPP counseling and testing centers. To ensure effectiveness, I-TECH will

facilitate necessary training for seven data clerks, be it at counseling and testing centers or care and

treatment sites, to ensure that the clerks are experts users of the system. Initially, the HMIS project will be

piloted at seven locations, MOD/NDF headquarters in Windhoek, Luiperd Valley, Suiderhof, and the four

counseling and testing centers in Grootfontein, Rundu, Okahandja and Walvis Bay. I-TECH will procure and

supply computer equipment and software with necessary accessories to accommodate the HMIS at all

these sites. A minimum of 5 computers will be needed at the MOD/NDF in the Directorate of Medical

Services for the HIV/AIDS Coordinator and the data clerks and a minimum of 3 computers per other sites

will be needed for the use of the Unit Commander, the senior medical officer and data clerk. To fulfill the

confidentiality requirement of the MOD/NDF, the HMIS system will be manned by military personnel and I-

TECH will ensure that these personnel receive adequate training and necessary assistance in the

confidentiality aspects. Moreover, I-TECH will provide assistance to the MOD/NDF to assume the overall

technical maintenance of the system.

In addition, I-TECH in close collaboration with the MOD/NDF, will continue to build the capacity of military

personnel to ensure appropriate program monitoring and evaluation, by identifying and deploying military

personnel to monitor and evaluate the program activities. Further collaboration in the area of M&E will be

maintained with the Ministry of Health and Social Services as this will enable the program to benefit and

stay in line with the National Health Information System (NHIS) for the purpose of monitoring at national

level. Furthermore, I-TECH will assist the MOD/NDF to devise an M&E plan in line with the plan for national

multi-sectoral monitoring and evaluation of HIV/AIDS.

It is important to know the HIV sero-prevalence within the military to plan effectively for HIV care and

treatment. In collaboration with the MOD and the MAPP prevention partner, I-TECH will conduct an HIV

sero-prevalence survey assuming concurrence of the MOD/NDF is finalized. The precise methodology (e.g.

mandatory testing of all personnel vs. anonymous testing on a sample of MOD/NDF members) will depend

on the outcome of the current HIV policy discussions within the military.

The Defense Attaché Office (DAO) PEPFAR program manager will manage this program and administer

funding through I-TECH Namibia. This activity will contribute significantly to the overall program area

priorities by generating monitoring and evaluation data in a most at risk population (MARP). Training of

M&E officers in the MOD will leverage curriculum development and training workshops coordinated by the

MOHSS and other USG partners. Empahasis areas include strategic information, local capacity building,

and workplace programs.

The Ministry of Defense/Namibian Defense Force (MOD/NDF) has developed a draft HIV/AIDS policy for

the military during FY 2006. I-TECH will provide technical assistance to the MOD/NDF to finalize and

launch the policy. About 2000 copies of the policy document will be printed in at least three different

languages and distributed to all critical personnel at the 23 bases/camps. In collaboration with the

Department of Defense Military Action & Prevention Program (DOD MAPP) prevention partner, I-TECH will

conduct training workshops to sensitize all commanders and their deputies to the content of the policy.

Furthermore, all HIV/AIDS coordinators at the 23 bases/camps, HIV/AIDS counselors and health care

providers at the military hospitals and clinics will receive a copy of the policy document and will also be

sensitized to its content. I-TECH with the support of the prevention partner will monitor the implementation

of the policy on a periodic basis and make recommendation to the MOD/NDF on possible modifications.

I-TECH will support the MOD/NDF to develop a short-term and long-term training plan for its health care

providers in order to ensure an efficient scaling up of ART services in the military.

With FY08 funds military physicians will be sent to participate in the Defense HIV/AIDS Prevention Program

(DHAPP) training in San Diego or in Uganda, as part of human capacity development in the military. In

addition, I-TECH--in collaboration with the MOD/NDF--will identify and send 5 military nurses, counselors

and doctors from the military ART program to sub-regional HIV/AIDS short-term training courses in FY

2008.

In order to ensure a committed management and leadership of the MAPP prevention, care, and treatment

program, I-TECH will support the participation of senior military officers to participate in the annual training

courses offered by the Defense Institute for Medical Operations (DIMO). At least two senior officials from

the MOD/NDF will participate in the resident DIMO (San Antonio) course on HIV/AIDS planning/policy

development and about 20 nurses and counselors will participate in one non-resident course (Namibia) on

leadership in HIV/AIDS program development during FY 2008.

I-TECH in collaboration with the prevention partner will explore the possibility of collaborating with a local

organization to conduct a comprehensive evaluation which will determine the relevance, quality and

effectiveness of the MAPP program.

The Defense Attaché Office (DAO) PEPFAR program manager will manage this program and administer

funding through I-TECH Namibia.