PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
NEW/REPLACEMENT NARRATIVE
This continuing activity supports six main components: (1) partial funding for community counselors (CCs);
(2) procurement of routine clinic supplies and equipment; (3) PMTCT training for traditional birth attendants
(TBAs); (4) support for an information, education, and communication (IEC) campaign promoting PMTCT;
(5) support for improved follow-up of mother-infant pairs; (6) provision of nutritional supplementation for
persons living with HIV/AIDS (PLWHA).
In supporting PMTCT services, the Ministry of Health and Social Services (MOHSS) is responsible for
national coordination, resource mobilization, monitoring and evaluation, training, and policy development.
1. Partial funding for Community Counselors. In FY 2009 COP, funding for CCs, who dedicate part of their
time to this activity, is distributed among six program areas in which the Ministry of Health and Social
Services (MOHSS) has activities: PMTCT (9%), Abstinence and Be Faithful (49%), Other Prevention (13%),
HIV/TB (8%), Counseling and Testing (12%), and HIV Treatment Services (9%).
The introduction of rapid testing performed by nurses and community counselors in FY 2006 COP, along
with an opt-out HIV testing strategy and linkages to ART has contributed to a large proportion of pregnant
women who now know their HIV status in antenatal care (ANC) and labor and delivery. MOHSS
established the CC cadre in 2004 to assist doctors and nurses with provision of HIV prevention, care, and
treatment services, including HIV counseling and testing (CT) services, PMTCT, ART, TB, and STI; and to
link and refer patients from health care delivery sites to community HIV/AIDS services. CCs, who perform
rapid HIV testing, play a major role in PMTCT as the primary providers of CT services in ANC in support of
the nursing staff.
The national Technical Advisory Committee (TAC) has revised PMTCT guidelines to reflect the 2006 WHO
recommendations to use combination ARV prophylaxis regimens for PMTCT that are more efficacious and
can potentially reduce the development of resistance to Nevirapine (NVP). The revised 2008 PMTCT
guidelines recommend use of AZT beginning at 28 weeks gestation or any time thereafter, single-dose NVP
and AZT/3TC given to the mother at the onset of labor, followed by a 7-day ‘tail' of AZT/3TC to the mother.
Infants receive SD NVP at 12-72 hours postpartum, followed by a seven-day ‘tail' of AZT/3TC. The regimen
for the infant differs from the WHO recommended AZT for four weeks. This was a deliberate decision taken
by the MOHSS TAC in recognition that in the few babies where PMTCT efforts are unsuccessful, the risk of
developing NVP resistance remains an important consideration, just as it is in the mother. Hence, the
recommendation is to administer AZT+3TC ‘tails' to babies as well.
Use of the new PMTCT regimen has already begun in some sites, especially in those sites that have ART
clinics staffed by experienced doctors and nurses who have already received training in the new PMTCT
regimen. Scale-up of the new regimen is expected in more than 50% of sites in 2009. Some health centers
and clinics may need additional training before they become confident in using the new regimen.
2. Procurement of supplies and equipment. Support to print ANC and maternity registers, and procure
clinic furniture and equipment for new PMTCT sites (scales, hemoglobinometers, lockable cabinets for ARV
drugs). Support will also assist in printing and dissemination of the new national PMTCT guidelines that
reflect the new WHO 2006 guidelines.
3. Training for TBAs. Training for an additional 80 TBAs on their role in PMTCT services, including
promotion of HIV prevention, reproductive health services for HIV-positive women, and referral of pregnant
HIV-positive women in the northern regions will be continued. Approximately 25% of deliveries in Namibia
occur outside of a health facility.
4. Support for an IEC campaign promoting PMTCT. A national educational campaign by the Directorate of
Primary Health Care to promote PMTCT services in collaboration with the Ministry of Information,
Communication and Technology (MICT) will continue in FY2009 COP. Funding will be provided to develop,
produce, and disseminate PMTCT educational materials for strategic communications in the clinical setting,
including the promotion of male involvement. Materials will be produced in local languages as appropriate.
5. Follow-up of mother-infant pairs. Linkages to care, treatment and support for the HIV-exposed baby,
mother and partner will become routine in PMTCT. This will be done through follow-up of the mother-infant
pair using the case managers recruited through Potentia, and through formalizing linkages with established
community structures to trace mother-infant pairs who fail to come back for scheduled PMTCT follow-up.
This activity will facilitate early care and initiation of cotrimoxazole (CTX) prophylaxis from as early as six
weeks of age for all HIV-exposed infants, and will facilitate early diagnosis of infection through DNA PCR.
These funds will support field supervision and monitoring of mother-infant follow-up efforts.
6. Provision of nutritional supplementation for PLWHA. Nutritional support for pregnant and lactating
women will be provided to meet the needs of a minimum of 10% of all HIV-positive pregnant women. This
activity will leverage new USG centrally funded food supplementation activities to be undertaken in public
health facilities. The activity will also leverage support from UNICEF and the Clinton Foundation which
provide commodity donations and TA for nutrition.
New/Continuing Activity: Continuing Activity
Continuing Activity: 16149
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
16149 3882.08 HHS/Centers for Ministry of Health 7365 1068.08 Cooperative $2,204,240
Disease Control & and Social Agreement
Prevention Services, Namibia U62/CCU02408
4
7334 3882.07 HHS/Centers for Ministry of Health 4383 1068.07 Cooperative $1,433,108
3882 3882.06 HHS/Centers for Ministry of Health 3134 1068.06 $793,550
Disease Control & and Social
Prevention Services, Namibia
Emphasis Areas
Gender
* Addressing male norms and behaviors
* Increasing gender equity in HIV/AIDS programs
* Reducing violence and coercion
Human Capacity Development
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $100,000
and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.01:
This activity includes one primary component: continued training and deployment of Community
Counselors (CCs). These CCs deliver appropriately targeted prevention messages and services in a wide
variety of health facility settings.
Within COP09, funding for Community Counselors (CCs), who dedicate part of their time to this activity, is
distributed among six program areas, all of them Ministry of Health and Social Services (MOHSS) activities:
Preventing Mother to Child Transmission (9%), Abstinence and Be Faithful (49%), Other Prevention (13%),
HIV/TB (8%), Counseling and Testing (12%), and ART Services (9%).
PEPFAR funding for the "Community Counselor package" includes: salaries for the 650 CCs who are
deployed in public health sites, including correctional facilities; 13 regional coordinators; a national
coordinator; and an assistant national coordinator (implemented through MOHSS in partnership with the
Namibian Red Cross Society). The package further includes refresher training (implemented by MOHSS
through a local training partner); supervisory visits by MOHSS staff persons who directly supervise the CCs;
support for planning meetings and an annual retreat for CCs. In COP09 the salaries for community
counselors, which has been held at US$230 per month since the program was implemented, will be
increased by 35%.
By the end of September 2008, a total of 495 CCs were deployed and working in MOHSS health facilities,
with a retention rate of 95%. Priority sites for deployment include ANC, TB clinics, ART clinics, and
outpatient departments (where nearly all STI cases are seen). With COP08 support, an additional 155 CCs
will be trained and deployed to give a cumulative total of 650 by September 2009. The additional CCs will
accommodate loss through attrition, enhance provision of outreach-based counseling and testing, initiate
counseling and testing (CT) services within correctional facilities and expand prevention with persons living
with HIV/AIDS (PwP) efforts. With COP09 funding, 300 deployed CCs will also receive refresher training in
rapid HIV testing, couples counseling, PwP, preventive care counseling for children, and Provider Initiated
HIV Testing and Counseling (PITC) in clinical settings. In addition, the IntraHealth-supported New Start
Counselors will receive refresher training through the MOHSS supported mechanism.
Community Counselor prevention activities include provision of condoms and ABC messages appropriately
targeted to at-risk persons defined by age, sex, HIV status, and presentation of other STIs. CCs are the
primary personnel at health sites responsible for providing CT services, and in this capacity, are well-
positioned to deliver prevention messages to those who test positive or negative. CCs are trained to
encourage clients to bring in their partners for CT services, providing opportunities to deliver prevention
messages to discordant couples (approximately 12% of couples who are tested at CT sites are discordant).
CCs will be trained in PwP counseling using CDC's curriculum for integration into counseling services within
ART and PMTCT sites.
A high proportion of CCs' clients will be sexually active HIV-positive patients in health facilities, providing an
opportunity for the PwP approach. Since October 2006, CCs have been receiving training in the PwP
approach (using CDC's curriculum) and are providing these counseling services at the ART sites to which
they are assigned. With COP09 funding, additional CCs will implement nationwide rollout of PwP in other
settings. CCs will promote couples counseling and encourage all their clients, but particularly people living
with HIV and AIDS, to reduce their high-risk behaviors through abstinence and being faithful to one partner.
Couples CT will also be reinforced to identify prevention opportunities with discordant couples.
All activities 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 trans-generational sex, power inequities between
men and women, and alcohol abuse.
Continuing Activity: 16150
16150 3875.08 HHS/Centers for Ministry of Health 7365 1068.08 Cooperative $2,674,711
7329 3875.07 HHS/Centers for Ministry of Health 4383 1068.07 Cooperative $2,375,000
3875 3875.06 HHS/Centers for Ministry of Health 3134 1068.06 $398,427
* Increasing women's legal rights
Estimated amount of funding that is planned for Human Capacity Development $2,207,128
Table 3.3.02:
This activity includes four primary components:
(1) continued training and deployment of Community Counselors (CC);
(2) procuring condoms for high-risk individuals;
(3) supporting the Ministry of Health and Social Services' (MOHSS) Coalition on Responsible Drinking
(CORD); and
(4) the initiation of one of three outreach teams to deliver prevention, care and treatment services to remote
communities.
1. Community Counselors
FY 2009 COP funding for Community Counselors (CCs) is distributed among six MOHSS program activity
areas:
• Abstinence and Be Faithful (49%)
• Other Prevention (13%)
• Counseling and Testing (12%)
• Preventing Mother to Child Transmission (9%)
• ARV Services (9%)
• HIV/TB (8%)
PEPFAR funding for the Community Counselors package will cover:
• salaries for the 650 CCs who are deployed in public health sites, including correctional facilities;
• 13 regional coordinators;
• one national coordinator;
• one assistant national coordinator (implemented through MOHSS in partnership with the Namibian Red
Cross Society);
• refresher training implemented by MOHSS through a local training partner;
• supervisory support visits by MOHSS staff persons who directly supervise the CCs; and
• support for planning meetings and an annual retreat for CCs.
In FY 2009 COP the salaries for CCs, which have been held at US$230 per month since the program was
implemented, will be increased by 35%. By the end of September 2008, a total of 495 CCs were deployed
and working in MOHSS health facilities, with a retention rate of 95%.
Priority sites for deployment include ANC, TB clinics, ART clinics, and outpatient departments (where nearly
all STI cases are seen). With FY 2008 COP support, an additional 155 CCs will be trained and deployed by
September 2009, bringing the cumulative total to 650. The additional CCs will accommodate loss through
attrition, enhance provision of outreach-based counseling and testing (CT), initiate CT services within
correctional facilities, and expand prevention with persons living with HIV/AIDS (PwP) efforts. With FY 2009
COP funding, 300 deployed CCs will also receive refresher training in rapid HIV testing, couples counseling,
PwP, preventive care counseling for children, and Provider Initiated HIV Testing and Counseling (PITC) in
clinical settings. In addition, the IntraHealth-supported New Start Counselors will receive refresher training
through the MOHSS supported mechanism.
primary personnel at health sites responsible for providing HIV CT, and in this capacity, are well-positioned
to deliver prevention messages to those who test both positive and negative. CCs are trained to encourage
clients to bring in their partners for CT, providing opportunities to deliver prevention messages to discordant
couples (approximately 12% of couples who are tested at VCT sites are discordant). CCs will be trained in
PwP counseling using CDC's curriculum for integration into counseling services within ART and PMTCT
sites.
2. Condom Procurement
The procurement of approximately six million condoms is a continuation of an activity added in 2007 to
leverage the support of the Global Fund, which provides support for the MOHSS' new Smile brand of male
condoms and for Femidom female condoms. The demand for the Smile condom brand has exceeded the
supply that MOHSS is able to purchase. Commodity Exchange is a local company which has been
contracted by the MOHSS to establish a condom production factory and quality assurance laboratory with
funding from the Global Fund. A 2005 USG-funded evaluation of condom supply and logistics evaluation
concluded that the quality assurance laboratory and plans for local production needed supplemental
support.
The MOHSS will use $420,000 of this activity's funding to meet a projected financial gap to purchase
additional Smile condoms and Femidoms with FY 2009 COP funding. These condoms will be distributed
free of charge to health facilities for use by high-risk clients (HIV-positive patients, discordant couples, STI
patients, TB patients, and patients having sex with a person of unknown HIV status) and for further
distribution to NGO/FBO partners for distribution to high-risk individuals (including mobile workers,
commercial sex workers, and the patrons of licensed and unlicensed community bars known as shebeens).
The planned number of condoms to be procured in Namibia in 2010 is over 20 million. Global Fund is
expected to fund 13 million condoms, PEPFAR six million, and the Namibian government one million.
3. Expansion of CORD
In a continuation of FY 2008 COP activities, USG funds will support expansion of the MOHSS' Coalition on
Responsible Drinking (CORD). CORD incorporates media messaging and works with community,
business, and health partners, as well as shebeens and breweries to reduce alcohol abuse, a major driver
of the HIV epidemic in Namibia. CORD will be rolled out to five additional regions of the country and will
use these funds to educate business owners and the general public about the association between alcohol
consumption, high-risk sexual behavior, and HIV transmission and acquisition.
Activity Narrative: 4. Outreach Team
In a new high-priority effort in FY 2009 COP, funding will support the implementation of three outreach
teams that will deliver prevention counseling, CT services, and ART services to remote areas of Namibia.
The other two outreach teams are reflected in MOHSS' efforts in the HTXS and HVCT program areas.
Despite MOHSS' impressive success in rolling out prevention, care and treatment services throughout the
country, there are many people who simply cannot reach the nearest health facility. The May 2008 National
Testing Day event clearly demonstrated that Namibians are eager to access outreach services.
Each mobile team will consist of a camper van, two community counselors each for testing and mobilization,
a nurse, and a driver. Using data and input from regional stakeholders, the teams will develop a monthly
schedule of visits to remote communities. The teams will be required to make the date of their visits
consistent (e.g. the first Thursday of each month). Teams will work in conjunction with DAPP field officers,
community leaders, and local radio stations to promote each outreach visit.
CT services will be implemented first. A regimented evaluation program will be put in place to determine
cost per client, success in reaching first-time testers, ability to link positive clients to treatment, and
community receptiveness. Once CT services are successfully implemented, ART will be phased in, one
team at a time. If the outreach teams are able to effectively deliver these services, other components may
be added, including TB screening and DOTs, PMTCT, case management, and alcohol counseling and
referrals.
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 men's lack of health care seeking behavior, multiple sex partners, transactional and trans-
generational sex, power inequities between men and women, and alcohol abuse.
Continuing Activity: 16151
16151 3880.08 HHS/Centers for Ministry of Health 7365 1068.08 Cooperative $1,277,751
7333 3880.07 HHS/Centers for Ministry of Health 4383 1068.07 Cooperative $1,150,000
3880 3880.06 HHS/Centers for Ministry of Health 3134 1068.06 $374,042
Estimated amount of funding that is planned for Human Capacity Development $601,878
Table 3.3.03:
This activity includes one primary component: provision of supplies, equipment, and commodities for male
circumcision.
As the demand for male circumcision (MC) increases within Namibia, there will be a need to ensure that the
appropriate supplies, equipment, and commodities are available. These supplies and commodities could
include, but are not limited to, surgical equipment, sterile equipment, local anesthetic, and patient education
materials.
In Namibia, there is an established MC task force that includes representatives from Ministry of Health and
Social Services (MOHSS), USG agencies, UNAIDS, and many other non-governmental organizations. The
MC task force will work closely with the MOHSS through its Central Medical Store to order, stock, and
distribute the appropriate supplies, commodities, and equipment needed. The distribution plan will be
dependent on the roll out plan for MC services. This plan will be determined by the MOHSS in 2009.
Traditional circumcisers perform circumcisions on males of any age, but primarily focus on neonates
through children aged three years. The MOHSS invited traditional circumcisers to the MC stakeholders
meeting that was held in 2008. The MOHSS is interested in working closely with this group to train, and
possibly certify and register the traditional male circumcisers. The MOHSS has expressed an interest in
distributing a male circumcision "supply pack" to traditional circumcisers in an attempt to improve safety and
sanitary conditions. The MOHSS would look for guidance and lessons learned from other countries (e.g.
Ghana) that have undertaken similar activities. Training would accompany supply pack distribution to
enhance overall safety and sanitary activities associated with traditional MC.
New/Continuing Activity: New Activity
Continuing Activity:
Table 3.3.07:
This continuing activity includes nominal support to the Ministry of Health and Social Services (MOHSS) for
gaps in equipment and supplies for established and future delivery points for ART and palliative care
services.
The MOHSS is responsible for national coordination, resource mobilization, monitoring and evaluation,
training, and policy development in support of all HIV and TB related services. The MOHSS manages a
network of more than 300 health facilities spread out over a vast geographic area in 13 health regions and
34 health districts. MOHSS leadership and implementation for facility-based palliative care for adult
persons living with HIV and AIDS (PLHWA) is within the framework of WHO's Integrated Management of
Adolescent and Adult Illness (IMAI) program. The IMAI Guidelines for Namibia have been approved, and
rollout of IMAI is continuing. The five IMAI modules include: (1) acute care; (2) chronic HIV care with ART;
(3) general principles of good chronic care; (4) palliative care; and (5) the caregiver booklet.
Taking on tasks previously provided by physicians, nurses will increasingly provide palliative care,
managing clients who are not yet eligible for ART as well as clients who have completed their first six
months of ART without incident. In COP09, CDC will recruit and hire a Namibian locally employed staff
(LES) as a palliative care technical advisor who will work alongside MOHSS counterparts in both the
Directorate of Special Programmes and the Directorate of Primary Health Care. The advisor will provide
continued technical support in COP09, especially to nurses who are supporting IMAI rollout in all 13 regions
of the country.
The majority of costs to support MOHSS' adult and pediatric care programming are reflected under CDC
(technical advisor), I-TECH (pre- and in-service training), Potentia (supplemental staff), HIVQUAL
(continuous quality assurance), and DAPP (linking persons in need to facility services). MOHSS care and
treatment activities are inextricable linked because the point of entry for accessing care services for many
HIV-impacted clients is during their routine ART clinic visits.
Funding under this activity supports procurement of equipment necessary to provide essential HIV-related
clinical care, including tools to improve clinical monitoring. In an effort to address barriers to proper care of
HIV-infected women, equipment will also be procured to improve gynecological screening and care of HIV-
positive women to more adequately address HIV-related conditions such as cervical dysplasia and
reproductive tract infections. Funding will further be used to replace outdated equipment in existing IMAI
sites as well as to procure new equipment for new sites joining the IMAI network. This includes office
supplies and tools essential for IMAI palliative care rollout, including printing of IMAI patient cards and files,
as well as scales, examination tables, lamps, and other standard clinical equipment.
Continuing Activity: 16153
16153 3877.08 HHS/Centers for Ministry of Health 7365 1068.08 Cooperative $280,329
7331 3877.07 HHS/Centers for Ministry of Health 4383 1068.07 Cooperative $266,980
3877 3877.06 HHS/Centers for Ministry of Health 3134 1068.06 $165,250
Table 3.3.08:
In FY 2009 COP, this continuing activity will support five primary components: 1) routine bioclinical
monitoring tests; 2) community counselors initiative; 3) support to severely malnourished persons living with
HIV/AIDS (PLWHA); 4) equipment and supplies for ART sites; and 5) mobile clinical services.
The Ministry of Health and Social Services (MOHSS) health care network comprises 31 district hospitals,
four referral hospitals, 35 health centers, and >240 clinics within hospital catchments. As of September
2008 the MOHSS reported that ART services were being provided in a total of 62 service points (36 static
sites and 26 outreach points). However, a recent pharmacy survey report conducted in May 2008 showed
that the total ART sites (static and outreach) was 101. The difference is explained by the fact that some
outreach service points do not yet have their own data capturing system and, as a result, their patients are
formally recorded and reported by the parent ART site.
According to the MOHSS electronic Program Monitoring System (ePMS), by the end of September 2008, a
total of 53,474 adult and pediatric patients were receiving treatment. Recent targets set by the MOHSS in
the "Estimates and Projections of the Impact of HIV/AIDS in Namibia" report released in June 2008 project
65,900 adults on treatment by the end of March 2010. Historical estimates suggest that approximately 85%
of these would be the charge of the public sector network.
1. Routine bioclinical monitoring tests. Funding will support MOHSS and mission-managed facilities for
routine bioclinical monitoring tests (CD4, viral loads, full blood counts, liver function tests, syphilis and
Hepatitis B screening, renal function tests, and other tests depending on regimen) performed by the
Namibia Institute of Pathology (NIP) for the anticipated 71,900 patients on ART in the 2010 calendar year.
Funding will also support CD4 monitoring of non-ART patients enrolled in palliative care at communicable
disease clinics (CDCs) and current and future IMAI sites. The Guidelines for ART Therapy in Namibia
stipulate which tests are to be performed.
These funds, which ultimately are used to reimburse NIP, are included in the MOHSS' Cooperative
Agreement rather than NIP's to increase the MOHSS' ownership and oversight of bioclinical monitoring
expenditures. The forthcoming Partnership Compact between the US Government and the Government of
the Republic of Namibia (GRN) will outline a timeline for GRN absorption of recurrent prevention, care and
treatment costs, including bioclinical monitoring tests.
Related to this component will be support for the MOHSS Technical Advisory Committee (TAC) to revise
and print the ARV treatment guidelines in line with adjustments in treatment recommendations over time.
The TAC has recommended the threshold for starting treatment be changed from the current CD4 cut-off of
200 cells in adults and 250 cells in pregnant women to a cut-off of 350 cells for all adults including pregnant
women. If formally adopted by the MOHSS top management, this is likely to greatly increase the number of
new patients eligible for treatment. Quantification of this increased patient load is still being done but it is
projected to have a substantial impact on laboratory and drug costs.
Given the high prevalence of HPV infection and cervical cancer among HIV positive women, a pilot cervical
cancer screening in HIV-positive women receiving care within treatment settings is proposed. Using I-
TECH funds, the MOHSS and I-TECH will collaborate to develop a concise, practical, on-site training
course for nurses and doctors to enhance their skills in doing PAP smears for cervical cancer screening.
Clinical Mentors and Nurse Tutors in the regions will pilot the training in three sites, training six
nurses/doctors per site. Following the pilot training, training will be done in six additional sites for six
participants at each site (36 participants total). Laboratory capacity will need to be strengthened to enable
quick turnaround of screening results.
While the MOHSS has indicated that it will be assuming the cost of all ARV drugs over time, increases in
laboratory costs will need to covered by PEPFAR for the time being until these recurrent costs can also be
assumed by the MOHSS. The Guidelines for the Clinical Management of HIV/AIDS are currently under
review and this process is now almost complete. The completion and adoption of these guidelines might
also see the MOHSS recommending Hepatitis B vaccination for HIV-infected adult patients who are found
to be Hepatitis B surface antigen negative who are also found to be non-immune to Hepatitis B.
The updated guidelines will also support the integration of the Prevention with Persons Living with HIV/AIDS
(PwP) Initiative within treatment and care settings.
Related to this specific activity, the MOHSS recently launched the guidelines for outreach and mobile HIV
counseling and testing (CT) protocol. Combined with the annual National HIV Testing Day (NTD) as well as
Provider Initiated Testing and Counseling (PITC) initiatives launched in May 2008, there is likely to be an
increase the demand for ARV services as a result of increased uptake of CT.
2. Community Counselors Initiative. PEPFAR funding for the "Community Counselor package" includes:
salaries for the 650 community counselors (CCs) who are deployed in public health sites, including
correctional facilities as well as 13 regional coordinators; a national coordinator; and an assistant national
coordinator. The CC Initiative is implemented through MOHSS in partnership with the Namibian Red Cross
Society. The Initiative further includes refresher training implemented by MOHSS through a local training
partner; supervisory visits by MOHSS staff persons who directly supervise the CCs; and support for
planning meetings and annual retreat for CCs. In FY2009 COP the salaries for community counselors,
which have been held constant since the Initiative began at approximately US $230 per month, will be
In FY2009 COP, funding for Community Counselors, who dedicate part of their time to this activity, is
PMTCT (9%), Abstinence and Be Faithful (49%), Other Prevention (13%), HIV/TB (8%), Counseling and
Testing (12%), and HIV Treatment Services (9%).
Activity Narrative: By end of September 2008, a total of 495 CCs were deployed and working in MOHSS health facilities,
reflecting a retention rate of 95%. Priority sites for deployment include ANC, TB clinics, ART clinics, and
outpatient departments (where nearly all STI cases are seen). With FY 2008 COP support, an additional
155 CCs will be trained and deployed to give a cumulative total of 650 by September 2009. The additional
CCs will accommodate loss through attrition, enhance provision of outreach-based CT, initiate CT services
within correctional facilities and expand PwP efforts. With FY2009 COP funding, 300 deployed CCs will
also receive refresher training in rapid HIV testing, couples counseling, PwP, preventive care counseling for
children, and PITC in clinical settings. In addition, the IntraHealth supported New Start Counselors will
receive refresher training through the MOHSS- supported mechanism. This refresher training will include
training on prevention with persons living with HIV and AIDS. Namibia is participating in the centrally
funded PWP initiative. As part of this initiative, there is a week long training course on PWP for community
counselors. The training course and corresponding materials will be modified for Namibia, and incorporated
into community counselor training. The community counselor PWP training materials will complement the
PWP training materials that will be developed by I-TECH that are targeted towards doctors and nurses.
3. Activities to address severely malnourished PLWHA who are on ART, including children. While MOHSS
policy does not support the provision of food parcels to outpatients within health care settings, it welcomed
a pilot with the Clinton Foundation/UNITAID to provide ready to use therapeutic feeding (RUTF) for
malnourished pediatric ART patients. The MOHSS is further partnering with the Namibian Red Cross
Society (NRCS) to refer PLWHA on ART for micronutrient supplementation and minimal targeted nutrition
supplementation referred by the Communicable Disease Clinics.
NRCS assigns USG-funded community counselors to Communicable Disease Clinics to provide CT and
they will link patients with NRCS nutrition points in the community. Using World Food Programme and
World Health Organization entry and exit criteria for food supplementation, the NRCS will provide a nutrition
supplement for either severely malnourished persons living with HIV on or eligible for ART as well as for any
pregnant or lactating woman on or eligible for ART. From the 2008 projections for new ART patients, an
estimated 10% of non-pregnant and non-lactating PLWHA, plus all pregnant and lactating PLWHA, will be
eligible for a six-month supply of a nutrition supplement. Based on these estimates, the program seeks to
target approximately 2,500 PLWHA. PEPFAR will support the NRCS to carry out procurement, supply
logistics, storage, monitoring, and distribution of the supplements. NRCS and MOHSS will also collaborate
to link recipients of the nutrition supplement with sustainable nutrition and income generating strategies
such as gardening projects in their communities.
4. Procurement of basic clinical equipment. Many of the existing and future ART facilities are ill-equipped
in terms of basic furniture and medical equipment such as examination beds; ear, nose and throat sets;
glucometers; hemoglobinometers; stadiometers; weighing scales; and filing cabinets. In FY 2009 COP, the
activity will continue to support the purchase of equipment and basic furniture with the specific goal of
supporting the decentralization of treatment services to new sites. In addition, as part of the roll out of PWP
activities in Namibia, based on lessons learned from the pilot implementation, we anticipate the need to
purchase equipment, furniture, and supplies to ensure the roll out of PWP activities in Namibia. This can
include, but is not limited to privacy screens, examination lights, specula, lithony stands, and the proper
beds, to conduct female examinations. In addition, there may be the need to purchase penile and pelvic
models, as well as educational materials for patient education.
5. Mobile HIV services. In a new high-priority effort in FY 2009 COP, funding will support the
implementation of three outreach teams that will deliver prevention counseling, CT services, and ART
services to remote areas of Namibia. The other two outreach teams are reflected in MOHSS' efforts in the
HVOP and HVCT program areas. Despite MOHSS' impressive success in rolling out prevention, care and
treatment services throughout the country, there are many people who simply cannot reach the nearest
health facility. The May 2008 National Testing Day event clearly demonstrated that Namibians are eager to
access outreach services.
Each mobile team will consist of a camper van, two community counselors for testing, two community
counselors for mobilization, a nurse, and a driver. Using data and input from regional stakeholders, the
teams will develop a monthly schedule of visits to remote communities. The teams will be required to make
the date of their visits consistent (e.g. the first Thursday of each month). Teams will work in conjunction
with DAPP field officers, community leaders, and local radio stations to promote each outreach visit.
CT services will be implemented first. A regimented monitoring and evaluation program will be put in place
to determine cost per client, success in reaching first-time testers, ability to link positive clients to treatment,
and community receptiveness. Once CT services are successfully implemented, ART will be phased in,
one team at a time. If the outreach teams are able to effectively deliver these aforementioned services,
other components may be added, including TB screening and DOTs, PMTCT, case management, and
alcohol counseling and referrals.
Continuing Activity: 16158
16158 3876.08 HHS/Centers for Ministry of Health 7365 1068.08 Cooperative $6,373,370
7330 3876.07 HHS/Centers for Ministry of Health 4383 1068.07 Cooperative $5,122,031
3876 3876.06 HHS/Centers for Ministry of Health 3134 1068.06 $3,950,056
Health-related Wraparound Programs
* Child Survival Activities
Table 3.3.09:
This activity includes two components: (1) support for basic clinical equipment required to provide pediatric
care services, and (2) support for DNA PCR tests required by Ministry of Health and Social
Services' (MOHSS) Early Infant Diagnosis Program.
HIV-infected children have been accommodated in the provision of care and treatment services since the
inception of the ART program in Namibia. The proportion of children in care has grown from 13% in the
early days of PEPFAR to a high of 16% in 2006. The program budget for care and support has been split to
reflect the estimated amount of resources spent on adult and pediatric care, which is respectively 85% and
15%.
1. Clinical Equipment and Supplies. This continuing activity includes nominal support to the MOHSS for
gaps in basic equipment and supplies for established Communicable Disease Clinics (CDCs) and the
peripheral health centers and clinics that will be added to the network of ART and Integrated Management
of Childhood Illnesses (IMCI) delivery sites in FY 2009 COP. Funding will be used to replace outdated
pediatric equipment in existing sites as well as to procure new equipment for sites joining the network. This
includes scales, examination tables, lamps, and other standard clinical equipment, as well as general office
supplies and tools essential for IMCI rollout, including printing of IMCI patient cards and files.
2. HIV DNA PCR testing for early infant diagnosis. This is a continuing activity previously funded under the
PMTCT program area. Namibia was one of the first countries to rollout DNA PCR in 2005 when the
MOHSS with CDC support developed and field tested the diagnostic algorithm for using dried blood spots
(DBS) and DNA PCR for early infant diagnosis. In 2006, the PMTCT program introduced DNA PCR for
symptomatic infants and HIV-exposed infants at six weeks of age.
Since that time, PEPFAR funds have and will continue to support training of technicians and technologists
from the Namibia Institute of Pathology (NIP) and other laboratories in PCR, purchase new equipment,
process specimens, and further the rollout of decentralized training of health workers in the collection of
DBS. In FY 2009 COP, the MOHSS will continue to receive direct funding to reimburse NIP for DNA PCR
testing. Providing the funding to the MOHSS rather than paying NIP directly ensures MOHSS ownership
and oversight of the program, the costs of which will be gradually absorbed by the MOHSS during the
course of PEPFARII. FY 2009 COP funds will support the costs of the 20,000 diagnostic PCR tests
projected to be performed.
* Safe Motherhood
Table 3.3.10:
In FY 2009 COP, this continuing activity will support three primary components: 1) routine bio-clinical
monitoring tests for pediatric patients; 2) community counselors initiative; 3) support to severely
malnourished persons living with HIV/AIDS (PLWHA); and 4) equipment and supplies for ART sites.
Namibia has generally tended to have fairly high proportions of children on ART relative to the total
population on treatment; currently 13% of patients on ART are children. In deciding to split the program
budget for care and treatment, a split of 15% to pediatrics and 85% to adults was agreed to reflect the
approximate amount of time and resources required for each.
This activity is a continuation from FY 2008 COP. The Ministry of Health and Social Services (MOHSS)
health care network comprises 31 district hospitals, four referral hospitals, 35 health centers, and >240
clinics within hospital catchments. ART services and facility-based chronic HIV care were offered by eight
public hospitals in 2003, 15 in 2004, 27 in 2005, all 35 public hospitals in 2006, 40 in 2007, and 62 thus far
in 2008. The 62 facilities include 35 district hospitals and 27 peripheral "outreach" sites, including some that
are not providing services on a daily basis. Due to the complexities of treating children, some facilities
provide all other aspects of pediatric care except provision of ARVs. According to the MOHSS' Response,
Monitoring and Evaluation Unit (RM&E) as of September 2008, a total of 53,474 patients are on ART, of
whom 6,845 are children under 15 years old. Since approximately 10% of treatment facilities are not
included in the electronic HIS, the numbers are likely to be under-reported. Recent targets set by the
MOHSS project 7,150 children on treatment by the end of 2009, and 14,300 in care; of these approximately
85% would be the charge of the public sector network, and 15% will be managed by mission sites.
training, and policy development in support of all HIV/AIDS related services. MOHSS recognizes an urgent
need to decentralize ARV services and transfer tasks from doctors to nurses. To this end, near the end of
2007, the MOHSS Directorate of Primary Health Care (PHC) adapted WHO's Integrated Management of
Childhood Illnesses (IMCI) training modules for Namibia to include PMTCT follow-up and pediatric ART.
The first training was conducted in August 2008, with 30 participants. Support for this has been received
from the Clinton Foundation and the MOHSS, though further funding is needed to take this to scale.
Legally, these nurses are not currently able to initiate ART, and would mostly help to increase referrals for
early care and treatment. The IMCI strategy has been rolled out and to date 22 facilities are providing
services. Each district hospital communicable disease clinic (CDC) is responsible for the rollout of IMCI to
one health center or clinic in their catchment area. Nurses in these sites will prescribe refills for ARVs for
PLWHAs after the first six months of treatment at a district CDC. However, it has been felt that these
nurses should first acquire enough experience in treating adults before being allowed to treat children.
Many of the existing and future ART facilities are ill-equipped in terms of basic medical equipment and
furniture. Lack of transport still impedes the ability of regional and especially district level supervisors to
follow-up on the status of services in peripheral health facilities. This activity supports four primary
components:
1. Routine bio-clinical monitoring tests. Funding will support MOHSS and mission-managed facilities for
routine bioclinical monitoring tests (CD4, full blood counts, ALT, Creatinine and Hepatitis B screening, and
other tests depending on regimen) performed by the Namibia Institute of Pathology (NIP) for the 7,150
children anticipated to be on ART in the 2009 calendar year. Funding will further support CD4 monitoring of
children not yet ART eligible, who are enrolled in care at CDCs and current and future IMCI sites. The
Guidelines for ART Therapy in Namibia stipulate which tests are to be performed. The Global Fund does
not provide financial support for bioclinical monitoring.
Agreement rather than NIP's to increase the MOHSS' ownership and oversight of bio-clinical monitoring
treatment costs, including bio-clinical monitoring tests.
2. Community Counselors Initiative. MOHSS established the community counselor (CC) cadre in 2004 to
assist doctors and nurses in healthcare facilities with provision of HIV prevention, care, and treatment
services, including HIV counseling and testing (CT), PMTCT, ART, TB, and STI; and to link and refer
patients from health care delivery sites to community HIV/AIDS services. Emphasis is placed on the
recruitment of HIV-positive individuals as CCs as a strategy to reduce stigma and discrimination. As of the
end of June 2007, 382 CCs (approximately 25% of whom are HIV-positive) had been placed at 253 health
facilities. By end of September 2008, 495 community counselors will be deployed in health facilities
throughout the country.
With FY 2008 COP funding, an additional 150 community counselors will be trained and deployed, giving a
cumulative total of 650. The additional counselors will accommodate loss through attrition, enhance
provision of outreach-based CT, expand prevention with persons with HIV/AIDS (PwP) efforts, and initiate
CT services in correctional facilities. The CC "package" includes: recruitment and salaries for the CCs, 13
regional coordinators, a national coordinator, and an assistant national coordinator (implemented through
the MOHSS' subcontract with the Namibian Red Cross Society); initial and refresher training (implemented
by a local training partner); supervisory visits by MOHSS staff who directly supervise the CCs; training for
MOHSS staff who are responsible for management of the program at national level; support for planning
meetings and an annual retreat for CCs; and support for MOHSS staff and CC participation at international
conferences.
Through serving in MOHSS CDCs, CCs are an important source of information and adherence counseling
to ART patients, including children. They also assist health professionals with basic administrative tasks in
the clinic and language interpretation for those who do not speak a local Namibian language. CCs'
messaging to adult ART patients includes bringing in children for ART follow-up.
Activity Narrative: 3. Support to severely malnourished PLWHA, including children. This component continues to fund
anthropometric measurements, monitoring, micronutrient supplementation, and minimal targeted nutrition
supplementation for severely malnourished PLWHA who are on ART, including children. While MOHSS
policy does not allow for provision of food to outpatients, it welcomed a pilot with the Clinton
Foundation/UNITAID to provide ready to use therapeutic feeding (RUTF) for malnourished pediatric ART
patients. The MOHSS is further partnering with the Namibian Red Cross Society (NRCS) to refer severely
malnourished children on ART for micronutrient supplementation and minimal targeted nutrition
supplementation and are referred by the CDCs. The NRCS already provides USG-funded CCs to CDCs to
provide CT services and they will link patients with NRCS access points in the community.
Using World Food Programme and World Health Organization entry and exit criteria for food
supplementation, the NRCS will provide a nutrition supplement for either severely malnourished children
living with HIV on or eligible for ART. From the 2008 projections for new ART patients, an estimated 10%
children in care and treatment will be eligible for nutrition supplementation. Based on these estimates, the
program seeks to target approximately 1,430 children. PEPFAR will support the NRCS to carry out
procurement, supply logistics, storage, monitoring, and distribution of the supplements. NRCS and MOHSS
will also collaborate to link recipients of the nutrition supplement with sustainable nutrition and income-
generating strategies such as gardening projects.
4. Procurement of basic furniture and equipment. Many of the existing and future ART facilities are ill-
equipped in terms of basic furniture and medical equipment such as lactate and hemoglobin meters, digital
thermometers, ENT scopes, infant and pediatric weighing scales, and measuring boards. In FY 2009 COP,
the activity will continue to support the purchase of equipment and basic furniture with the specific goal of
supporting the decentralization of treatment services to new sites.
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $15,000
Table 3.3.11:
**THE BELOW ACTIVITY NARRATIVE WAS CHANGED IN APRIL 2009 REPROGRAMMING DUE TO
THE USD$200,000 FUNDING CHANGE FROM HVCT & HVSI TO HVTB**
FUNDING: $828,046
• $478,046 original budget
• $200,000 MoHSS HVSI (TB DRS)
• $150,000 MoHSS HVCT (HIV test kits)
NEW/REPLACEMENT NARRATIVE (reprogramming April 2009)
This activity includes four primary components: (1) continued training and deployment of Community
Counselors (CCs) to ensure HIV testing of tuberculosis (TB) patients, (2) procurement of HIV rapid test kits
for testing of TB patients, (3) support laboratory diagnosis and bioclinical monitoring for TB, and (4) support
Namibia's 2010 TB drug resistance survey.
1. Community Counselors.
In COP09, funding for Community Counselors, who dedicate part of their time to testing of TB patients and
suspects, is distributed among six program areas, all of them Ministry of Health and Social Services
(MOHSS) activities:
• Preventing Mother to Child Transmission (9%),
• Abstinence and Be Faithful (49%),
• Other Prevention (13%),
• HIV/TB (8%),
• Counseling and Testing (12%), and
• ARV Services (9%).
Although the CCs are distributed over six budget areas, the proportion of the budget approximately mirrors
the amount of time CCs spend in these programmatic areas.
PEPFAR funding for the "Community Counselors package" includes: salaries for the 650 CCs who are
through a local training partner); supervisory support visits by MOHSS personnel who directly supervise the
CCs; support for planning meetings, and an annual retreat for CCs. In COP09 the salaries for CCs, which
have been held at US$230 per month since the program was implemented, will be increased by 35%. The
CCs have not had a salary increase since the inception of the CC program in 2004. The Permanent
Secretary of MOHSS formally requested the 35% salary increase so that the salary would attract and
maintain high quality counselors who increasingly take on additional essential program activities.
counseling and testing services within correctional facilities and expand prevention with persons living with
HIV/AIDS (PwP) efforts. With COP09 funding, 300 deployed CCs will also receive refresher training in rapid
HIV testing, couples counseling, PwP, and preventive care counseling for children and Provider Initiated
primary personnel at health sites responsible for providing HIV testing and counseling, and in this capacity,
are well-positioned to deliver prevention messages to those who test both positive and negative. CCs are
trained to encourage clients to bring in their partners for counseling and testing (CT) and providing
opportunities to deliver prevention messages to discordant couples (approximately 12% of couples who are
tested at VCT sites are discordant). CCs will be trained in PwP counseling using CDC's curriculum for
integration into counseling services within ART and PMTCT sites.
Community Counselor training includes a module on TB. Supervised by a nurse, CCs are the primary
personnel at health sites responsible for providing HIV testing and counseling to TB patients. In 2007, 54%
of TB patients were tested for HIV; 59% of these TB patients were HIV positive. Evidence from the 1st and
2nd quarter TB reviews indicates that HIV testing of TB patients is reaching 80%. This is due, in large part,
to the CCs that are designated to TB care and treatment settings.
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 trans-
2. Procurement of HIV Test Kits and Supplies for testing of TB patients and suspects
With PEPFAR support, MOHSS will continue to purchase the following: Determine and Unigold test kits
(using a parallel testing algorithm) to be used at MOHSS sites for HIV testing of a projected 50,000 TB
patients and suspects; ELISA or a new MOHSS-approved rapid test device will be used as a tie-breaker in
rare instances of discordance; HIV rapid test starter packs to launch new testing sites; and rapid HIV test
supplies for training CCs. Test kits and supplies for a projected 250 MOHSS sites will be procured and
Activity Narrative: distributed to health facilities by the MOHSS' Central Medical Stores through existing mechanisms.
3. Lab diagnosis and bioclinical monitoring for TB.
In 2008, Namibia reported over 300 cases of multidrug resistant TB (MDR TB), and as of October 2008,
approximately 20 cases of Extensively Drug Resistant TB (XDR TB) have been confirmed. This situation
has increased the use of cultures (C) and drug susceptibility testing (DST) testing for diagnosing and
monitoring TB patients and suspects. The request for C/DST is expected to increase with the planned
adoption of more aggressive and efficient MDR/ XDR case finding, as well as diagnosis of HIV-positive,
smear negative, pediatric TB suspects and contacts. The MOHSS reimburses the National Institute of
Pathology (NIP) for all bioclinical tests done for the public sector patients; these funds will be used to
support the MOHSS for the payment of TB diagnosis and C/DST bills.
4. TB Drug Resistance Survey
In 2008 the MOHSS conducted a national TB drug resistance survey. Due to delays with protocol review
and changing guidance about inclusion of anonymous unlinked HIV testing in such a survey, CDC's
technical assistance to the survey had to be limited. CDC and the MOHSS will repeat the TB drug
resistance survey in 2010, with an HIV testing component.
Continuing Activity: 16154
16154 7972.08 HHS/Centers for Ministry of Health 7365 1068.08 Cooperative $459,786
7972 7972.07 HHS/Centers for Ministry of Health 4383 1068.07 Cooperative $250,000
* TB
Estimated amount of funding that is planned for Human Capacity Development $373,481
Table 3.3.12:
THE USD$150,000 FUNDING CHANGE FROM HVCT TO HVTB**
This activity is a continuation of COP08 activities and includes four primary components: (1) The
Community Counselor Initiative, (2) procurement and distribution of HIV test kits and supplies, (3) promotion
of counseling and testing through Namibia's National HIV Testing events and (4) provision of outreach-
based counseling and testing services which is a new activity.
1. Community Counselor Initiative
FY 2009 COP funding for Community Counselors (CCs), who dedicate part of their time to this activity, is
distributed among six program areas through Ministry of Health and Social Services (MOHSS) activities:
HIV/TB (8%), Counseling and Testing (12%), and ARV Services (9%).
through a local training partner); supervisory visits by MOHSS staff who directly supervise the CCs; support
for planning meetings and an annual retreat for CCs. In FY09 the salaries for community counselors, which
has been held at US$230 per month since the program was implemented, will be increased by 35%.
counseling and testing services within correctional facilities and expand prevention with positives (PwP)
efforts. With FY09 funding, 300 deployed CCs will also receive refresher training in rapid HIV testing,
couples counseling, prevention with positives (PwP), and preventive care counseling for children and
Provider Initiated HIV Testing and Counseling (PITC) in clinical settings. In addition, the IntraHealth-
supported New Start Counselors will receive refresher training through the MOHSS supported mechanism.
2. Procurement of HIV Test Kits and Supplies
(using a parallel testing algorithm) to be used at MOHSS sites for HIV testing of a projected 100,000 clients;
ELISA or a new MOHSS-approved rapid test device will be used as a tie-breaker in rare instances of
discordance; HIV rapid test starter packs to launch new testing sites; and rapid HIV test supplies for training
CCs. Funding to support MOHSS' testing of an additional 50,000 clients who are TB patients or TB
suspects are reflected in the HVTB program area.
Test kits and supplies for a projected 250 MOHSS sites will be procured and distributed to health facilities
by the MOHSS' Central Medical Stores through existing mechanisms. A parallel rapid HIV test kit and
supply system to cater for a projected 25 New Start and MOD sites will be continued through SCMS in
FY09. The MOHSS will continue to carry out a feasibility assessment for implementing oral fluid rapid HIV
testing in specific settings, including outreach and correctional settings.
3. Promotion of CT through an Annual National HIV Testing Event
In FY08, the MOHSS held its first ever National HIV Testing Event over three days which witnessed a total
of 33,760 persons getting tested and receiving results. Two-thirds of these testers were being tested for the
first time. While men are generally underrepresented in accessing routine CT services, they represented
40% of the testers during this event. With the success of the National Testing Event in 2008, Ministry of
Health is planning to promote two CT events in FY09 with a newly added regional event coinciding with the
World AIDS Day commemoration. Funding will be used to support promotional activities in all 13 regions,
including drama presentations, radio announcements, other entertainment/educational events, speeches by
national and local leaders, and production and distribution of print and electronic media. As is the tradition in
Namibia, the World AIDS Day commemoration will be done in one of the regions identified by the MOHSS.
Outreach-based HIV counseling and testing services will be provided during World AIDS Day for the first
time with the 2008 event.
4. Provision of Outreach Counseling and Testing Services
This is one of the new priority areas for FY09. The MOHSS launched Guidelines for Outreach/Mobile
Counseling and Testing Services towards the end of 2007. In 2008, the MOHSS was able to carry out a
very successful National HIV Testing event that witnessed, for the first time in Namibia, the use of
outreach/mobile-based services. Given the vast distances and rural populations of Namibia,
outreach/mobile services are critical to providing HIV and other public health services to all corners of the
country. In FY09, funding will be used to support the pilot provision of mobile/outreach CT services in
accordance with the national strategy. Funding will support procurement of 2 mobile/outreach vans, related
equipment, and personnel.
Continuing Activity: 16156
16156 3926.08 HHS/Centers for Ministry of Health 7365 1068.08 Cooperative $681,804
7336 3926.07 HHS/Centers for Ministry of Health 4383 1068.07 Cooperative $777,000
3926 3926.06 HHS/Centers for Ministry of Health 3134 1068.06 $821,898
Estimated amount of funding that is planned for Human Capacity Development $520,000
Table 3.3.14:
This activity includes one component: funding support to procure FDA-approved ARVs through the Ministry
of Health and Social Services' Central Medical Stores.
This is a continuation of activities initiated in FY06. The Central Medical Stores (CMS) of the Ministry of
Health and Social Services (MOHSS) procures and distributes all ARVs in Namibia in the public sector,
including mission-managed health facilities. Through a single procurement structure, the CMS uses funds
from the MOHSS, the USG, the Global Fund, and other partners, including the Clinton Foundation, to
simplify procurement and maximize purchasing power.
The PEPFAR FY 2009 COP Budget Committee unanimously agreed to temporarily remove $2.5 million
from the MOHSS' ARV funding in FY 2009 COP. USG will restore these funds once a Partnership
Compact is signed between the US and the Government of the Republic Namibia (GRN). The GRN has
clearly signaled that its first step toward sustainability is absorption of all ARV costs. In 2007, the GRN
commissioned a costing exercise from the European Commission to project future HIV/AIDS costs,
including ARVs.
In 2008, the GRN agreed to absorb ARV costs previously covered by the Global Fund and further indicated
the intension to absorb ARV costs covered by PEPFAR by 2012. As a result, the USG has listed this effort
as one of the milestones toward sustainability in the Partnership Compact. Once the Compact is signed,
the $2.5 million required for PEPFAR's portion of ARV costs for Namibia will be restored as USG's sign of
good faith and commitment to work with the GRN to progress toward total Namibian ownership of its HIV
programming.
As of September 2008, ART services had rolled out to 101 sites in Namibia, including a number of outreach
sites conducting regular, but not daily, clinics. In FY07, 41,285 individuals had received treatment, including
5,609 (13.6%) children. ART services remain congested at a number of sites, and the continuing focus of
the national ART program is to: 1) decentralize care and treatment, 2) focus on quality of care and
treatment, 3) incorporate prevention and family planning messages into treatment, 4) improve "user
friendliness" of ARV services, 5) improve linkages to TB and PMTCT services as well as with community-
based organizations, 6) roll-out prevention with positives strategies nationwide (excepting three control sites
involved in the PwP pilot study), and 6) increase the involvement of people living with HIV/AIDS (PLWHAs)
in palliative care and/or adherence support programs to strengthen the adherence strategy.
By 2010, an anticipated 66,854 persons will be on ART in Namibia. Namibia has standardized first and
second-line regimens. Currently, 71% of adults on first-line regimens are currently on
stavudine/lamivudine/nevirapine (d4T/3TC/NVP) or zidovudine/lamivudine/nevirapine (AZT/3TC/NVP), 21%
are on stavudine/lamivudine/efavirenz (d4T/3TC/EFV) or AZT/3TC/EFV, and 8% are on a tenofovir (TDF)
containing regimen. Only 2% of patients on ART are on second-line regimens. New national treatment
guidelines were released in April 2008 which moved ART away from d4T due to toxicity. The MOHSS and
its partners are assessing the financial implications of these new treatment regimens, as well as the costs
associated with adopting a higher CD4 threshold for initiating ART.
The Clinton Foundation/UNITAID will continue to work with CMS to negotiate substantial price reductions
for CMS for pediatric and second-line drugs, and signed a multi-year memorandum of understanding with
the MOHSS to continue to assist CMS with bringing down drug costs in 2008. These negotiations have
resulted in the addition of low-cost pediatric fixed dose combination (FDCs) to CMS' formulary, which is
likely to substantially improve adherence and efficacy and reduce wastage from previous regimens which
involved messy and difficult-to-measure syrups.
In 2007, a procurement plan for 2007 was developed and implemented by the MOHSS, the USG and the
Global Fund to consolidate drug procurement through the CMS. Currently, 93% of the drugs procured with
PEPFAR funds are FDA-approved generics and 7% are FDA-approved branded products. Funds from
MOHSS and other donors will continue to be used to procure non-FDA-approved products. The supply
chain for ARVs and related drugs works well and cost-effectively in Namibia, with state-of-the-art pharmacy
information system and inventory practices that have virtually eliminated ARV stock-outs.
Continuing Activity: 16157
16157 3883.08 HHS/Centers for Ministry of Health 7365 1068.08 Cooperative $4,152,489
7335 3883.07 HHS/Centers for Ministry of Health 4383 1068.07 Cooperative $4,500,000
3883 3883.06 HHS/Centers for Ministry of Health 3134 1068.06 $3,600,000
Program Budget Code: 16 - HLAB Laboratory Infrastructure
Total Planned Funding for Program Budget Code: $2,311,413
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
In FY 2009 COP, the US Government (USG) laboratory support team will continue its strong collaboration with the Namibia
Institute of Pathology (NIP), first initiated in FY 2007 COP, to provide laboratory services in support of HIV and HIV-related
prevention, treatment, and care.
Contributions of a USG-funded laboratory scientist stationed at the NIP continue to provide enhancement to molecular
diagnostics, particularly the introduction of diagnostic DNA PCR testing. Validation of dried blood spot samples for diagnostic
DNA PCR testing at the NIP and development of a new diagnostic algorithm for early diagnosis in HIV-exposed and symptomatic
infants were accomplished in FY 2006 COP. Capacity for performing viral load assays has also been implemented in the central
laboratory and a national policy has been adopted for use of the assay when drug resistance is suspected and for all patients six
months after initiation of HAART.
Expertise in TB testing will be of critical importance due to ongoing surveillance for drug-resistant TB. Laboratory staff will also
contribute to prevention activities by screening for TB and assisting with STI diagnosis, among other activities. Costs for bio-
clinical monitoring are covered under MOHSS. A costing analysis of the USG-supported laboratory services is planned to be
conducted with FY 2008 COP funding.
In addition, in FY 2009 COP trainings will be supported for NIP technical and managerial staff from the central and peripheral
laboratories based on an ongoing assessment of training needs. Training activities will continue to be focused on laboratory
management and will include development of a strategic plan for national laboratory services, a feasibility assessment for
establishing a national public health laboratory, bio-clinical monitoring of testing technologies and instrumentation, and quality
systems for TB and opportunistic infections (OIs). The USG will continue to work with the International Lab Consortium Partners
(ILB) to deliver training. In addition to the short-term training, the USG will continue to support the Polytechnic of Namibia's (NIP)
Medical Technology School long term training through the American International Health Alliance (AIHA) twinning program
described in the OHSS program area.
The first threshold survey of drug-resistant HIV using the 2006 national sentinel survey specimens was completed in 2007; the
testing was performed at the National Institute for Communicable Diseases (NICD) in South Africa by a Namibian scientist. Such
testing continues to be a priority for FY 2009 COP, although capacity limitations within NIP and the MOHSS will remain
challenges. In FY 2009 COP, NIP and the MOHSS will continue threshold surveys at sentinel sites using 2008 ANC sentinel
surveillance specimens as well as using early warning indicators and monitoring HIV drug resistance at selected ARV sites.
Arrangements will be made for Namibians to complete training on viral RNA extraction and genetic sequencing at NICD in South
Africa.
In FY 2007 COP, the Partnership for Supply Chain Management (SCMS) project facilitated the design of a new laboratory
logistics management system for the NIP. This design was developed in close collaboration with all key stakeholders, including
USG-funded implementing organizations and other donor organizations, including the Global Fund. In FY 2009 COP, this activity
will continue with focus on strengthening the effectiveness and efficiency of NIP's laboratory supplies logistics system.
The Namibian Ministry of Defence (MOD) and National Defence Force (NDF) uses the laboratory facilities of NIP for testing
purposes. Emphasizing the unique nature of the military and the issue of confidentiality of data, the MOD has expressed the need
to establish their own laboratory facilities within the military hospitals where ART services will be provided. The first MOD lab was
established in FY 2008 COP and another lab will be established at another MOD ARV site in FY 2009 COP. NIP will support
these initiatives with PEPFAR funding.
As part of improving the quality of services, and to reduce turnaround times for results, laboratory testing will be further
decentralized and transportation of specimens and results reporting will be improved at remote facilities. More facilities will be
connected to the USG-supported lab information system at NIP (MEDITECH) to improve access to lab results. NIP staff will also
participate in planned PHEs and will have regular meetings with clinical staff to review quality of services.
NIP is a national network of thirty six laboratories covering the whole country. There is one central reference lab in Windhoek,
regional labs in Oshakati (northwest) and Rundu (northeast), and additional sub-regional and health facility laboratories.
NIP is a para-statal institution, receiving fees for services to the MOHSS and private institutions. PEPFAR provides funding to pay
these fees to the MOHSS rather than directly to NIP to increase MOHSS oversight and ownership of the bio-clinical monitoring
program. Recurrent costs such as these fees are expected to be among the first costs targeted for absorption by the MOHSS
when a Partnership Compact is developed between USG and the Government of the Republic of Namibia (GRN).
Major challenges in Namibia related to laboratory services include the lack of qualified laboratory professionals who are Namibian
and willing to work in the public sector, and the vastness of the country. Another challenge is the rapid roll-out of care and
treatment services to the whole country without commensurate decentralizing of laboratory services. The national laboratory
strategic plan will be developed with assistance from the Association of Public Health Laboratories.
The partnership with international institutions, the planned medical technologists training program at the Polytechnic of Namibia
and the development of an NIP training policy, through FY 2009 COP support, will assist Namibia in strengthening laboratory
capacity to support all health care programs.
Table 3.3.16:
THE USD$200,000 FUNDING CHANGE FROM HVSI TO HVTB**
FUNDING: $510,000 ($710,000 original - $200,000 to HVTB)
Within this activity there are two main components: (1) Ministry of Health and Social Services (MOHSS)
Response, Monitoring and Evaluation (RM&E) support; and (2) antenatal care (ANC) sentinel surveillance
2010 support.
Timely data collection, processing and reporting are essential to measure progress in the National Strategic
Plan for HIV/AIDS and to improve services through program evaluation and public health evaluation. The
following activities are supported with this funding:
1. MOHSS RM&E Support
a. Computer equipment and connectivity:
The following items will be procured in order to continue and expand the capture, processing, and
dissemination of routine ART/PMTCT/CT/TB data. It will ensure computer equipment and patient forms are
available and in working order for both newly recruited and established data capture and processing
personnel.
i) Computers, including monitors, printers, and uninterrupted power supplies will be procured for all new
data clerks and health information systems officers in all ART/PMTCT/CT/TB clinic sites. Where necessary,
replacement equipment will be provided for existing data clerks. We assume a replacement of 10% of the
computers in the field and will include replacement parts for computer systems that require maintenance.
ii) Software (including antivirus) upgrades.
iii) Memory sticks (65) for ease of transferring files will be purchased for new data staff.
iv) Fast, secure email access to all facility and regional informatics personnel.
Rapid, efficient, secure exchange of data is critical to program monitoring and improvement, but it remains a
challenge in Namibia.
v) In FY2006/07COP patient care books were updated to conform to WHO standards. This activity will
support production of approximately 20,000 patient books during FY2009COP.
vi) 3G devices for wireless communication by RM&E staff while in the field.
vii) Three laptop computers will be purchased to facilitate training and travel by RM&E staff.
b. Produce patient record forms and site registers for collection and dissemination of routine
ART/PMTCT/CT/TB data:
Provision of ART is a complicated endeavor and thorough record keeping is critical to ensure quality patient
care. The MOHSS has developed patient booklets and registers to facilitate this record keeping. Record
keeping is also essential to PMTCT, TB treatment, and voluntary counseling and testing. This activity will
support routine printing of necessary forms, booklets, and registers and their dissemination to the site level.
c. Support medium-term training:
One of the major challenges facing the Namibian response to HIV/AIDS is limited human capacity. Human
capacity strengthening through short courses (workshops) has limited ability to provide the more
sophisticated skills needed to generate high quality SI in Namibia. This activity will support medium-term
training courses (2-4 weeks) for 3-6 staff members from the national RM&E steering committee. This
support will cover airfare, tuition, room and board for the participants.
d. Printing and dissemination of RM&E Annual Report:
Dissemination of RM&E reports is essential to inform program managers and policy makers of the HIV/AIDS
response. This activity will support the printing and dissemination of this report. Printing will be contracted
to the lowest local bidder who is trustworthy and dissemination will occur through regional level
dissemination workshops coordinated by the RM&E sub-division.
e. Provide training on database server
In FY2008COP, the USG supported the procurement of a database server to be housed at the Office of the
Prime Minister, which will house the various program databases and make them available to those who
need to use the data. MOHSS data analysts will be trained in management of data on an SQL server. This
will allow efficient management of health data at the central level.
f. Office furniture for RM&E renovated space
The response to HIV/AIDS in Namibia has grown exponentially in recent years and the RM&E staff needs to
experience similar growth to ensure strategic information is available to support program and policy. The
current RM&E staff complement is limited by the office space available to them. FY2007COP support
renovated existing space into which RM&E is continuing to expand. This activity will provide office furniture
for expansion into that space. This space is co-located with the national health information systems offices
to facilitate collaboration between these related subdivisions.
g. Strengthen monitoring and evaluation capacity at government governing bodies and umbrella
organizations:
Quality monitoring and evaluation (M and E) will require capacity building at line ministries and umbrella
organizations for civil society. This activity will provide M and E courses for M and E officers at these
organizations.
2. ANC Sentinel Surveillance 2010
Every two years the MOHSS conducts an ANC Sentinel Survey to measure HIV prevalence among
pregnant women. This funding will support the planning, tool development, training of selected sites,
supportive supervision visits to each participating site, the analysis of the results, and the printing and
dissemination of the final report.
Continuing Activity: 16159
16159 3879.08 HHS/Centers for Ministry of Health 7365 1068.08 Cooperative $409,146
7332 3879.07 HHS/Centers for Ministry of Health 4383 1068.07 Cooperative $558,520
3879 3879.06 HHS/Centers for Ministry of Health 3134 1068.06 $266,000
Estimated amount of funding that is planned for Human Capacity Development $100,000
Table 3.3.17:
This activity, funded since COP05, provides scholarships (bursaries) to train Namibian students to become
health professionals. Since COP05, PEPFAR has supported a total 943 bursaries for Namibians to study
medicine, nursing, pharmacy, social work, public health, and other allied health fields.
Inadequate human resource capacity is among the leading obstacles to the development and sustainability
of HIV/AIDS-related health services in Namibia. The USG has recognized pre-service training as
instrumental in sustainability of HIV efforts in Namibia, and despite a reduced budget this year, this is one
area prioritized for expansion. Funding in COP09 for bursaries has increased by 18% from COP08.
There is a critical human resources gap at facility levels to delivery of HIV prevention, care, and treatment
services in Namibia. The lack of pre-service training institutions for doctors and pharmacists in Namibia,
coupled with limited ability to train other allied health professionals, contributes to a chronic shortage of
health professionals who can provide comprehensive services on the scale and at the level of quality that is
required. In 2007, the vacancy rate in the Ministry of Health and Social Services (MOHSS) was 35% for
doctors, 22% for registered nurses, 26% for enrolled nurses, and 41% for pharmacists.
Other non-PEPFAR resources from the USG are leveraged to improve Namibia's somewhat weak
secondary education to prepare students for health careers. This includes support from the Millennium
Challenge Account for textbooks and the Ambassador's Scholarship Program that support scholarships for
young girls to attend grades 8 through 12.
COP09 will support bursaries for a minimum of 400 Namibians to train as doctors, pharmacists, pharmacy
assistants, nurses, enrolled nurses, laboratory technologists, social workers, public health administrators,
epidemiologists, and nutritionists in Namibia, South Africa, and Kenya. Students are bonded to serve the
MOHSS upon completion of studies and will work in an area related to HIV/AIDS. In addition to these fields
of study, further support for monitoring and evaluation and information technology training is outlined in the
MOHSS' HVSI program narrative.
While some students will receive bursaries to study outside of Namibia, many others will receive bursaries
to enroll in pre-service programs in Namibia supported with PEPFAR funds. These pre-service programs
include the nursing and pharmacy training programs at the National Health Training Center (NHTC) and
University of Namibia (UNAM), the medical technology training program at the Polytechnic of Namibia
(PoN), and the public health program at UNAM.
1. Nursing and Pharmacy Training. To fill urgently needed nursing and pharmacy positions, this activity will
support MOHSS plans to increase the output of enrolled nurses and pharmacy assistants from the NHTC,
who can be trained in two years instead of four years, and for registered nurses at UNAM. These positions
are urgently needed as task-shifting and Integrated Management of Adult Illness (IMAI) continues to be
rolled out.
2. Medical Technology Training. PEPFAR will support up to 20 bursaries for students in the laboratory
technologist program at the PoN, which began enrolling students in January 2008. This new program is
supported by PEPFAR through a twinning relationship between PoN and the University of Arkansas for
Medical Sciences, through AIHA.
3. Public Health Training. Bursaries will also support students who enroll in the PEPFAR-supported MPH
program in public health leadership and certificate programs in monitoring and evaluation and nutrition.
These programs were initiated with COP08 funds to support a twinning arrangement with a TBD school of
public health and UNAM.
Once funding is approved, PEPFAR will work with the MOHSS' Division of Public Policies and Human
Resources Development (PPHRD) to assess current and future needs as well as long- and short-term costs
to determine the exact number and type of bursaries that will be supported. In 2009, PEPFAR will work in
collaboration with PPHRD to ensure that the bursary program is widely advertised throughout Namibia and
to update and refine the application process for the program.
Continuing Activity: 16160
16160 3874.08 HHS/Centers for Ministry of Health 7365 1068.08 Cooperative $806,857
7328 3874.07 HHS/Centers for Ministry of Health 4383 1068.07 Cooperative $809,308
3874 3874.06 HHS/Centers for Ministry of Health 3134 1068.06 $212,500
Estimated amount of funding that is planned for Human Capacity Development $950,000
Table 3.3.18:
