Detailed Mechanism Funding and Narrative

Years of mechanism: 2008 2009

Details for Mechanism ID: 1157
Country/Region: Namibia
Year: 2009
Main Partner: U.S. Centers for Disease Control and Prevention
Main Partner Program: NA
Organizational Type: Own Agency
Funding Agency: HHS/CDC
Total Funding: $5,713,567

Funding for Biomedical Prevention: Prevention of Mother to Child Transmission (MTCT): $559,448

NEW/REPLACEMENT NARRATIVE

This continuing activity has two main components: (1) support for a CDC PMTCT technical advisor (TA)

placed in the Ministry of Health and Social Services (MOHSS), and (2) support for two PMTCT field support

nurses who cover the northern regions of Namibia and are based at Oshakati State Hospital.

USG will to continue to work closely with MOHSS at the national, regional and service levels in the 34

health districts to provide technical expertise during the roll-out and strengthening of PMTCT services, to

monitor the implementation at existing service delivery sites, and to support expansion of services from 238

facilities currently providing PMTCT services to all 258 antenatal care (ANC) sites nationally.

Namibia began PMTCT services in early 2002 at two public hospitals. In late 2002, the Global AIDS

Program of HHS/CDC began its collaboration with Namibia's MOHSS by providing technical assistance in

PMTCT, VCT, TB/HIV, surveillance, and ART services. The overall responsibilities for coordinating and

rolling out of PMTCT services lie with the MOHSS Primary Health Care (PHC) Deputy Director in the Family

Health Division. A PMTCT Coordinator employed through the Global Fund and a full-time USG-supported

PMTCT TA assist the Deputy Director in carrying out these activities. The USG also supports training,

information systems, logistics and technical assistance to the national PMTCT program. Specific activities

include:

1. Support for a PMTCT Technical Advisor to the MOHSS. This position will support a national counterpart

in the PHC Directorate with PMTCT program roll-out, and will be involved with developing and revising

guidelines related to PMTCT. The training of health workers to build their competencies to be able to

deliver quality PMTCT services is an important area of responsibility for the PMTCT TA. The TA will assist

with curriculum development activities for PMTCT, early infant diagnosis of HIV, ART, Pediatric ART,

Integrated Management of Adult Illness (IMAI), infant feeding, and other related curricula. In addition,

supervisory support visits will be undertaken to provide mentoring and technical backstopping to the

regions. Monitoring the effectiveness of the PMTCT program is an ongoing activity through the MOHSS

Health Information System, and the TA will support the regions with utilization of information generated from

the PMTCT database.

2. Funding for two HHS/CDC PMTCT field support nurses who cover the northern regions and are based at

Oshakati State Hospital. Working with Ministry staff at the national, regional, and district level, these nurses

conduct crucial supervisory support visits to current and newly-operational PMTCT sites to provide on-site

monitoring, training, and assessment of the quality of services, patient flow, and record keeping as well as

to identify challenges and needs.

The roll-out of rapid testing in PMTCT also requires hands-on support to health facilities. The

CDC/Oshakati staff also support sites to integrate the wide range of HIV prevention, treatment, and care

services into the clinical setting and improve linkages with local non-governmental organizations (NGOs).

Approximately 25% of women do not deliver in health facilities and these nurse supervisors assist with the

identification and training of traditional birth attendants in PMTCT. They are stationed in Oshakati State

Hospital, the largest hospital in the north, where the MOHSS has allocated office space to HHS/CDC in

order to facilitate logistical, material, and technical support to the area.

The field nurses have been assisting health facilities in four regions (Oshana, Oshikoto, Ohangwena and

Omusati). In FY2009 COP they will expand their support to Kunene and Kavango regions. CDC/Oshakati

field nurses partner with other programs to identify needs, facilitate and implement supportive programs.

This activity leverages resources with the Global Fund, which is funding a PMTCT Coordinator, training,

diagnostic PCR testing, and three PMTCT trainers at the national level.

Pending clarification/approval from the OGAC PHE working group, CDC will continue to support a Public

Health Evaluation of infant feeding practices in the context of HIV. This activity will roll into 2009, but will be

supported by FY2007 COP funds, as well as Global Fund resources.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16238

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16238 3856.08 HHS/Centers for US Centers for 7390 1157.08 $416,648

Disease Control & Disease Control

Prevention and Prevention

7357 3856.07 HHS/Centers for US Centers for 4389 1157.07 $360,120

Disease Control & Disease Control

Prevention and Prevention

3856 3856.06 HHS/Centers for US Centers for 3128 1157.06 $108,986

Disease Control & Disease Control

Prevention and Prevention

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $559,448

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.01:

Funding for Sexual Prevention: Abstinence/Be Faithful (HVAB): $226,885

NEW/REPLACEMENT NARRATIVE

This activity includes one primary component: continuing support of a CDC Prevention Technical Advisor to

the Ministry of Health and Social Services (MOHSS) Directorate of Special Programmes on HIV prevention

and behavior change communication.

In late 2002, CDC's Global AIDS Program of HHS/CDC began its collaboration with Namibia by opening an

office in the MOHSS National AIDS Coordination Program (now known as the Directorate of Special

Programmes) to provide technical assistance in PMTCT, VCT, TB/HIV, surveillance, and ART services. In

response to requests from the MOHSS, CDC has gradually formed a team of technical advisors at the

national level, including two direct hires, and technical advisers in the areas of adult and pediatric

care/treatment, PMTCT, VCT, SI, palliative care, and laboratory services. While the MOHSS has made

substantial progress in terms of rolling out treatment, PMTCT, and VCT in the emergency phase of

PEPFAR, less attention has been given to establishing a comprehensive systematic national prevention

strategy based on best practices and evidence-based interventions.

In 2007, the Director of Special Programmes recognized the shortcomings and lack of leadership in

prevention and requested the support of a behavioral scientist to build local capacity in the use of evidence-

based approaches to design national prevention programs. This assistance is critical as it will come as the

MOHSS is staffing the "Expanded National Response" subdivision and implementing WHO's

Communication for Behavior Change Interventions (COMBI) program within the Directorate. Both of these

efforts focus on behavior change and strategic communications. Therefore, the local environment is well

suited for continued assistance from a USG Technical Advisor (TA) on prevention.

In 2008, the MOHSS hired a prevention coordinator for the first time with PEPFAR support. The MOHSS

prevention coordinator will provide technical leadership and vision on prevention issues and the USG

prevention advisor will work closely with his MOHSS counterpart to plan and implement prevention

programming.

The TA will work with the MOHSS to develop capacity to provide national leadership on the most evidence-

based prevention strategies available, including behavioral change interventions and medical interventions

(e.g. circumcision, microbicides, etc.) as they become available. The TA will support a process to adapt

best practices from other countries and to promote dissemination of best practices from within Namibia at

the national and international level. This will include ongoing support to the head of the Counseling and

Testing unit in the Directorate to roll out, monitor, and evaluate the Prevention with Persons Living with

HIV/AIDS (PwP) intervention through community counselors and health workers. The PwP initiative

incorporates "be faithful" messaging to discordant couples and thus contributes to AB efforts. This TA will

further support Namibia's Male Norms Initiative, with particular emphasis on:

a. defining and promoting strategies that result in abstinence or sexual postponement for adolescent boys,

b. male partner reduction,

c. greater willingness to access services,

d. transactional and trans-generational sex,

e. power inequities between men and women, and

f. abuse of alcohol.

The TA will also support efforts to streamline DAPP's training curricula for field officers and to harmonize

messaging with other in-country prevention efforts. The TA will work with DAPP to adopt curricula

incorporating AB messaging proven to be effective.

In a new initiative begun with COP08 funding, Potentia will hire and I-TECH will train 34 case managers with

psychology or social work backgrounds for deployment to ART and ANC sites throughout the country. The

TA will play a key role in developing scopes of work, hiring criteria, and selecting suitable candidates, as

well as for assisting I-TECH with developing a training curriculum for this cadre. These case managers will

contribute to AB efforts by facilitating support groups, providing couples and PwP counseling, and referring

clients for health and social services that can support prevention efforts.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16239

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16239 8001.08 HHS/Centers for US Centers for 7390 1157.08 $157,500

Disease Control & Disease Control

Prevention and Prevention

8001 8001.07 HHS/Centers for US Centers for 4389 1157.07 $150,000

Disease Control & Disease Control

Prevention and Prevention

Emphasis Areas

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

* Increasing women's access to income and productive resources

* Increasing women's legal rights

* Reducing violence and coercion

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $226,885

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.02:

Funding for Sexual Prevention: Other Sexual Prevention (HVOP): $75,000

NEW/REPLACEMENT NARRATIVE

This activity includes one primary component: support for the replication and expansion of the National

Male and Female Leadership Conferences on HIV/AIDS.

In February 2008, the Ministry of Health and Social Services (MOHSS) convened a conference for

Namibian male leaders entitled "Namibian Men and HIV/AIDS, Our Time to Act." The meeting was chaired

by the President of Namibia, His Excellency Hifekepunye Pohamba. The goal of this meeting was to

engage male leaders in order to enhance their involvement in the response to the HIV/AIDS epidemic.

Through plenary and breakout sessions, the forum provided an opportunity for leaders to discuss the factors

that play a role in male involvement and to solicit their opinions on future activities that would attract and

involve men in HIV/AIDS activities. The meeting was attended by over 150 male leaders, including the

Prime Minister, parliamentarians, and ministers, as well as military, business, and religious leaders. Some

of the specific commitments made by men at the conference include:

a. Serving as role models for HIV testing,

b. Replicating the Male Conference at the regional level,

c. Promoting responsible drinking to consumers and alcohol vendors,

d. Exploring the role of male circumcision in HIV prevention,

e. Encouraging and supporting interventions developed by and targeted towards men, and

f. Integrating messages about HIV/AIDS in speeches.

Leaders raised the level of awareness about the relationship between men's behavior and the spread of

HIV, discussed ways in which men can participate in the response to the epidemic, and encouraged men to

make a strong commitment to prevent the spread of HIV.

In May 2008, UNAIDS and the MOHSS convened the first Namibian Women Leaders Conference on

HIV/AIDS. The conference provided a platform for female leaders to come together and discuss HIV/AIDS

and its impact in their homes and communities. The conference was initiated by the First Lady of Namibia,

Her Excellency Penehupifo Pohamba. The meeting was attended by political officials (Cabinet Ministers

and Deputy Ministers, Members of Parliament and National Council, Governors, Mayors/Deputy Mayors),

civil society leaders, private sector leaders, doctors, members of academia, etc. Female leaders came up

with numerous recommendations to address HIV on the personal, community, and national level.

Many male and female leaders who attended the conferences were motivated to participate in the May 9th

National HIV Testing Day.

In COP09, CDC will support the MOHSS with the replication of the National Male and Female Conferences

on HIV/AIDS as well as the rollout of similar conferences at the regional and district level. The replication of

the national conferences will help measure progress in achieving stated commitments and outline further

action items. The regional conferences will help attract traditional and community leaders.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

* Increasing women's access to income and productive resources

* Increasing women's legal rights

* Reducing violence and coercion

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $75,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.03:

Funding for Care: Adult Care and Support (HBHC): $75,000

NEW/REPLACEMENT NARRATIVE

The funds from this activity cover 75% of salary and personnel-related costs for a Palliative Care Technical

Advisor to the Ministry of Health and Social Services (MOHSS). The remaining funds are reflected in the

Pediatric Care and Support (PDCS) program area.

The MOHSS is gradually shifting tasks from physicians to nurses, enabling nurses to provide palliative care,

and to manage clients not yet eligible for ART and those who have received their first six months of ART at

hospital communicable disease clinics. This transition is part of MOHSS' decentralization plans to support

comprehensive HIV/AIDS care for Namibian communities, as outlined in the Integrated Management of

Adult Illness (IMAI) and Integrated Management of Childhood Illness (IMCI) guidelines, which are based on

standards set forth by the World Health Organization (WHO). The IMAI and IMCI guidelines set forth a

framework for decentralized HIV/AIDS training, service delivery standards, and task shifting of care to

district and community levels. Namibia's 13 regions are anticipated to complete the roll-out of IMAI to

selected health centers and clinics in their catchment areas by 2009.

As a result of continued training and roll-out of IMAI and IMCI in Namibia, expertise in provision of care

services is improving. In FY 2006 COP, the USG and its partners, including the MOHSS, began receiving

technical assistance from the African Palliative Care Association (APCA) and a USAID Regional Technical

Advisor for HIV/AIDS Palliative Care. Support from APCA will continue in FY 2009 COP. While significant

program accomplishments are underway with this technical support, there remains a critical need to have

an in-country, experienced, full-time palliative care technical advisor who is dedicated to development,

decentralization, monitoring and evaluation of HIV-related palliative care in Namibia. The technical advisor

will assist with continued roll-out and quality assurance of HIV-related adult and pediatric care services,

including support for the national IMAI and IMCI programs. The position was first approved in FY 2007

COP through the CTSGlobal/Comforce mechanism. In FY 2009 COP, this position will be converted to a

locally employed staff (LES) position for a qualified Namibian.

In this position, the technical advisor will:

1. Directly support MOHSS care programming at facility levels, including support for implementation and

monitoring of IMAI and IMCI.

2. Support the current MOHSS Coordinator for Palliative Care and Opportunistic Services in the

Directorate of Special Programs to develop that individual's expertise and leadership.

3. Serve as a liaison to the MOHSS Case Management Unit's implementation efforts; CDC's HIVQUAL

Coordinator; the extensive I-TECH trainings and mentorship programs; the IMAI site nurses and their

referring district ART doctors.

4. Collaborate closely with the MOHSS Family Health Division, which is responsible for community-based

palliative care, clinical nutrition and family planning/HIV integration, as well as USG partners to address

other critical program gaps. This includes partnering with:

a. MOHSS' Nutrition Subdivision and I-TECH's Nutrition Advisor to ensure that developments in clinical

nutrition are well integrated into HIV/AIDS palliative care programs;

b. MOHSS' Family Health Division in the Primary Health Care Services Directorate and the Global Fund to

strengthen the delivery of community-home based care and the integration of palliative care at home and

community levels;

c. MOHSS ART sites, Central Medical Stores, and SCMS to address gaps in procurement and supply

chain management for home based care kits and essential palliative care medications.

The technical advisor will emphasize key palliative care priorities across program areas and will include the

provision of the preventive care package for adults and children which includes:

a. Cotrimoxizole prophylaxis for Stage III, IV disease or CD4<300 and for HIV-exposed/infected children,

b. TB screening and the "three Is" (infection control, isoniazid preventive therapy, and intensified case

finding),

c. Integrated counseling and testing,

d. Infant feeding counseling for HIV-positive mothers,

e. Child survival interventions for HIV-positive children,

f. Growth monitoring and immunizations,

g. Clinical nutrition counseling,

h. Anthropometric measurement, monitoring, referral, micronutrient supplementation and targeted nutrition

supplementation for severely malnourished people living with HIV and AIDS (PLWHA) who are on ART,

i. Prevention strategies which include balanced ABC prevention messaging, condoms, support for

disclosure of status, referral for PMTCT services, reduction in alcohol use and gender-based violence

including assistance as needed through government centers for abused women and children.

Key palliative care priorities also include other opportunistic infection management, ART adherence, routine

clinical monitoring, and systematic pain and symptom management. Closer partnerships with districts and

communities will allow increased opportunities to expand safe water and hygiene strategies as well as to

expand access to malaria prevention for PLWHA and their families. It is also anticipated that a complete roll

-out of IMAI task-shifting will ultimately result in MOHSS' development of a national palliative care policy

that allows nurses to prescribe narcotics and symptom-relieving medications. Technical support from APCA

(#8043) will support this activity.

The technical advisor will ensure gender-sensitive approaches, including equitable training and support of

male and female health care workers, with the goal of equal access to services for PLWHA and their

families throughout USG-supported programs.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

Health-related Wraparound Programs

* Child Survival Activities

* Family Planning

* Malaria (PMI)

* Safe Motherhood

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $75,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.08:

Funding for Treatment: Adult Treatment (HTXS): $444,073

NEW/REPLACEMENT NARRATIVE

FY 2009 COP funds will be used to support: (1) Salary and personnel-related costs for CDC's HIVQUAL

Technical Advisor, and (2) a portion of the costs of general office management, travel and training related to

the continued rollout of the HIVQUAL program in Namibia.

Funding for HIVQUAL is split between HTXS, PDTX, HBHC and PDCS because the program focuses on

quality improvement of clinical services in all four areas.

1. HIVQUAL Technical Advisor. Funding for this activity will be specifically directed for HIVQUAL Namibia

in-country activities through the CDC/Namibia office and led by the HIVQUAL Technical Advisor. This

activity will expand on the HIVQUAL work which began in Namibia in FY 2007 COP to reach 16 ART sites.

In FY 2009 COP the program will add new sites throughout all 13 regions to reach all 34 public and faith-

based district hospitals. In addition, all health centers providing HIV care and treatment will be targeted

during FY 2009 COP. These funds will be used to support salaries and benefits for the locally based

HIVQUAL Technical Advisor.

Since FY 2007 COP, PEPFAR has funded a technical advisor to assist the Ministry of Health and Social

Services (MOHSS) with rollout of the HIVQUAL program via a non personal services contract. By FY 2009

COP, this position will be converted to a personal services contract (PSC). While increasing costs

somewhat, this conversion is necessary for two primary reasons: (1) to reflect the inherently governmental

functions of these positions, and (2) to rectify the double taxation of these positions by both the US and

Namibian governments. The double taxation results from the lack of a ratified bilateral agreement between

the two countries that covers non-PSC positions. While reducing taxation costs, this conversion will result

in increased ICASS costs.

2. HIVQUAL program administration, travel and training. FY 2009 COP funds will be used to support

general administration of the HIVQUAL program, as well as in-country travel for quality improvement (QI)

coaching and training costs related to rolling out the HIVQUAL program in adult treatment settings as

outlined below.

In FY 2009 COP, HIVQUAL activities will be conducted under the leadership of the MOHSS Directorate of

Special Programs (DSP) in close collaboration with the HIVQUAL Technical Advisor. The US-based

HIVQUAL team will provide technical support for quality improvement specifically in adult treatment. The

HIVQUAL project will support capacity building for QI for health facilities managed and supported by four

local organizations, namely MOHSS, Catholic Health Services, Lutheran Health Services, and Anglican

Health Services. The improved quality of care at these facilities is expected to benefit the estimated 71,900

adult patients on treatment by March 2010. These treatment estimates are obtained from the MOHSS HIV

estimates report released in June 2008 based on Spectrum projections.

Specific activities will include:

a. QI training;

b. Assessment of quality management programs at the participating clinics;

c. Performance measurement (at six-month intervals) of selected core indicators;

d. Ongoing QI coaching at participating sites;

e. Promotion of consumer engagement in HIV care;

f. Regular conference calls with the US-based team;

g. Development and dissemination of QI related IEC materials including the HIVQUAL International

Newsletter.

Planned activities will strengthen systems of care and documenting strategic information in health care

facilities. An important emphasis of this approach is to develop providers' skills for collecting and using

performance data within their own organizations to improve their systems of care. Use of facility-level data

derived from the national health information system for the purpose of improving quality is an important goal

of HIVQUAL.

HIVQUAL is uniquely facility- and region-specific. At the clinic level, QI methods can be adapted to each

organization's particular systems and capacities. An assessment tool to measure the capacity of the quality

management program at each facility is used which not only measures the growth of quality management

activities but also guides the coaching interventions. Aggregate facility-specific data can provide population

-level performance data that indicate priorities for national quality improvement activities and campaigns.

Publication and dissemination of these data will be done under the auspices of the MOHSS.

Regionally, networks of providers who are engaging in quality improvement activities can work together to

address problems that are unique to each area, including, for example, human resource shortages and

coordination of care among multiple agencies as well as adherence to care services. QI training will be

conducted for groups of providers. The project will work in partnership with all treatment partners who will

help disseminate QI improvement strategies and activities throughout their networks.

The concept of QI using the HIVQUAL model is still relatively new in Namibia. Consequently, a great deal

of in-person advocacy and training will be required to increase awareness and buy-in of the initiative by

health care providers at peripheral sites. Advocacy material for QI will be printed and disseminated to

health care facilities.

Effective leadership in quality and safety in health care means having access to the most recent information

and practical experience. The sharing of best practices is necessary to learn from each other's experiences

and promote quality improvement. The national coordinators of HIVQUAL under the Case Management

Unit of the MOHSS will thus participate in QI conferences to learn from others and share experiences.

Special Note: While not directly funded in this program area, CDC's Deputy Director of Programs will

Activity Narrative: further support the MOHSS' adult treatment activities. This position is funded under systems strengthening

and is currently vacant. The Deputy Director of Programs position will be held by a medical officer who will

spend most of his or her time working with the MOHSS Directorates of Special Programmes and Primary

Health Care to establish and rollout guidelines and policies as well as to provide field support and technical

assistance in the areas of PMTCT, VCT, TB/HIV, medical prevention, and adult and pediatric care and

treatment services.

New/Continuing Activity: Continuing Activity

Continuing Activity: 17364

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

17364 17364.08 HHS/Centers for US Centers for 7390 1157.08 $171,968

Disease Control & Disease Control

Prevention and Prevention

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $444,073

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.09:

Funding for Care: Pediatric Care and Support (PDCS): $25,000

NEW/REPLACEMENT NARRATIVE

The funds from this activity cover 25% of salary and personnel-related costs for a Palliative Care Technical

Advisor. The remaining funds are reflected in the Adult Care and Support (HBHC) program area

The Ministry of Health and Social Services (MOHSS) is gradually shifting tasks from physicians to nurses,

enabling nurses to provide palliative care, and to manage clients not yet eligible for ART and those who

have received their first six months of ART at hospital communicable disease clinics. This transition is part

of MOHSS' Integrated Management of Adult Illness (IMAI) and Integrated Management of Childhood Illness

(IMCI) guidelines, which are based on standards set forth by the World Health Organization (WHO). The

IMAI and IMCI guidelines set forth a framework for decentralized HIV/AIDS training, service delivery

standards, and task shifting of care to district and community levels. Namibia's 13 regions are anticipated to

complete the rollout of IMAI to selected health centers and clinics in their catchment areas by 2009.

These funds will support a technical advisor to the MOHSS for continued roll-out and quality assurance of

HIV-related adult and pediatric care services, including support for the national IMAI and IMCI programs.

This position was first approved in FY 2007 COP through the CTSGlobal/Comforce mechanism. In FY

2009 COP, this position will be converted to a locally employed staff (LES) position for a qualified Namibian.

As a result of continued training and roll-out of IMAI and IMCI in Namibia, expertise in provision of care

services is improving. In FY 2006 COP, the USG and its partners, including the MOHSS, began receiving

technical assistance from the African Palliative Care Association (APCA) and a USAID Regional Technical

Advisor for HIV/AIDS Palliative Care. Support from APCA will continue in FY 2009 COP. While significant

program accomplishments are underway with this technical support, there remains a critical need to have

an in-country, experienced, full-time palliative care technical advisor who is dedicated to development,

decentralization, monitoring and evaluation of HIV-related palliative care in Namibia.

In this position, the technical advisor will:

1. Directly support MOHSS care programming at facility levels, including support for implementation and

monitoring of IMAI and IMCI.

2. Support the current MOHSS Coordinator for Palliative Care and Opportunistic Services in the Directorate

of Special Programs to develop that individual's expertise and leadership.

3. Serve as a liaison to the MOHSS Case Management Unit's implementation efforts; CDC's HIVQUAL

Coordinator; the extensive I-TECH trainings and mentorship programs; the IMAI site nurses and their

referring district ART doctors.

4. Collaborate with the MOHSS Family Health Division, which is responsible for community-based palliative

care, clinical nutrition and family planning/HIV integration

5. Work with USG partners to address other critical program gaps. This includes partnering with:

a) MOHSS' Nutrition Subdivision and I-TECH's Nutrition Advisor to ensure that developments in clinical

nutrition are well integrated into HIV/AIDS palliative care programs;

b) MOHSS' Family Health Division in the Primary Health Care Services Directorate and the Global Fund to

strengthen the delivery of community-home based care and the integration of palliative care at home and

community levels;

c) MOHSS ART sites, Central Medical Stores, and SCMS to address gaps in procurement and supply

chain management for home based care kits and essential palliative care medications.

The technical advisor will emphasize key palliative care priorities across program areas and will include the

provision of the preventive care package for adults and children. Elements of this package include:

a. Cotrimoxizole prophylaxis for Stage III, IV disease or CD4<300 and for HIV-exposed/infected children;

b. TB screening and the "three Is" (infection control, isoniazid preventive therapy, and intensified case

finding);

c. Integrated counseling and testing;

d. Infant feeding counseling for HIV-positive mothers;

e. Child survival interventions for HIV-positive children;

f. Growth monitoring and immunizations;

g. Clinical nutrition counseling;

h. Anthropometric measurement, monitoring, referral, micronutrient supplementation and targeted nutrition

supplementation for severely malnourished people living with HIV and AIDS (PLWHA) who are on ART; and

i. Prevention strategies which include balanced ABC prevention messaging, condoms, support for

disclosure of status, referral for PMTCT services, reduction in alcohol use and gender-based violence

including assistance as needed through government centers for abused women and children.

Key palliative care priorities also include other opportunistic infection management, ART adherence, routine

clinical monitoring, and systematic pain and symptom management. Closer partnerships with districts and

communities will allow increased opportunities to expand safe water and hygiene strategies as well as

expand access to malaria prevention for PLWHA and their families. It is also anticipated that a complete roll

-out of IMAI task-shifting will ultimately result in MOHSS' development of a national palliative care policy

that allows nurses to prescribe narcotics and symptom-relieving medications. Technical assistance from

APCA (#8043) will support this activity.

The technical advisor will ensure gender-sensitive approaches, including equitable training and support of

male and female health care workers with the goal of equitable access to services for PLWHA and their

families throughout USG-supported programs.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

* Reducing violence and coercion

Health-related Wraparound Programs

* Child Survival Activities

* Family Planning

* Malaria (PMI)

* Safe Motherhood

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $25,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.10:

Funding for Treatment: Pediatric Treatment (PDTX): $25,795

NEW/REPLACEMENT NARRATIVE

FY 2009 COP funds will be used to support one component: a portion of the costs of general office

management, travel and training related to the continued rollout of the HIVQUAL program in Namibia.

Funding for HIVQUAL is split between HTXS, PDTX, HBHC and PDCS because the program focuses on

quality improvement of clinical services in all four areas.

Funding for this activity will be specifically directed for HIVQUAL Namibia in-country activities through the

CDC/Namibia office and led by CDC's HIVQUAL Technical Advisor. This activity will expand on the

HIVQUAL work which began in Namibia in FY 2007 COP which a goal of reaching 16 ART sites. In FY

2008 COP the program will add at least 18 new district sites throughout all 13 regions of the country and

reach all 34 public and faith-based district hospitals. In FY2009COP, HIVQUAL will further target at least

five health centers providing pediatric HIV treatment. Specifically, these funds will be used to support

general office management for the HIVQUAL program in Namibia, as well as travel and training costs

related to rolling out the HIVQUAL program to improve pediatric care and treatment as outlined below.

In FY 2009 COP, HIVQUAL activities will be conducted under the leadership of the Ministry of Health and

social Services (MOHSS) Directorate of Special Programs (DSP) in close collaboration with the HIVQUAL

Technical Advisor. The US-based HIVQUAL team will provide technical support for quality improvement

specifically in adult treatment. The HIVQUAL project will support capacity building for QI for health facilities

managed and supported by four local organizations, namely MOHSS, Catholic Health Services, Lutheran

Health Services, and Anglican Health Services. The improved quality of care at these facilities is expected

to benefit the estimated 5,900 pediatric patients on treatment in these facilities by March 2010. These

treatment figures were obtained from the MOHSS HIV Estimates report released in June 2008 based on

Spectrum projections.

Specific activities will include:

a. QI training;

b. Assessment of quality management programs at the participating clinics;

c. Performance measurement (at six-month intervals) of selected core indicators;

d. Ongoing QI coaching at participating sites;

e. Promotion of consumer engagement in HIV care;

f. Regular conference calls with the US-based team;

g. Development and dissemination of QI related IEC materials including the HIVQUAL International

Newsletter.

Planned activities will strengthen systems of care and documenting strategic information in health care

facilities. An important emphasis of this approach is to develop providers' skills for collecting and using

performance data within their own organizations to improve their systems of care. Use of facility-level data

derived from the national health information system for the purpose of improving quality is an important goal

of HIVQUAL.

HIVQUAL is uniquely facility- and region-specific. At the clinic level, QI methods can be adapted to each

organization's particular systems and capacities. An assessment tool to measure the capacity of the quality

management program at each facility is used which not only measures the growth of quality management

activities but also guides the coaching interventions. Aggregate facility-specific data can provide population

-level performance data that indicate priorities for national quality improvement activities and campaigns.

Publication and dissemination of these data will be done under the auspices of the MOHSS.

Regionally, networks of providers who are engaging in quality improvement activities can work together to

address problems that are unique to each area, including, for example, human resource shortages and

coordination of care among multiple agencies as well as adherence to care services. QI training will be

conducted for groups of providers. The project will work in partnership with all treatment partners who will

help disseminate QI improvement strategies and activities throughout their networks.

The concept of QI using the HIVQUAL model is still relatively new in Namibia. Consequently, a great deal

of in-person advocacy and training will be required to increase awareness and buy-in of the initiative by

health care providers at peripheral sites. Advocacy material for QI will be printed and disseminated to

health care facilities.

Effective leadership in quality and safety in health care means having access to the most recent information

and practical experience. The sharing of best practices is necessary to learn from each other's experiences

and promote quality improvement. The national coordinators of HIVQUAL under the Case Management

Unit of the MOHSS will thus participate in QI conferences to learn from others and share experiences.

Special Note: While not directly funded in this program area, CDC's Deputy Director of Programs will

further support the MOHSS' adult treatment activities. This position is funded under systems strengthening

and is currently vacant. The Deputy Director of Programs position will be held by a medical officer who will

spend most of his or her time working with the MOHSS Directorates of Special Programmes and Primary

Health Care to establish and rollout guidelines and policies as well as to provide field support and technical

assistance in the areas of PMTCT, VCT, TB/HIV, medical prevention, and adult and pediatric care and

treatment services.

New/Continuing Activity: Continuing Activity

Continuing Activity: 17364

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

17364 17364.08 HHS/Centers for US Centers for 7390 1157.08 $171,968

Disease Control & Disease Control

Prevention and Prevention

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $25,795

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 12 - HVTB Care: TB/HIV

Total Planned Funding for Program Budget Code: $3,657,504

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

In COP 09, the US Government (USG) will continue to work with the Namibian government and other partners to improve access

to and quality of tuberculosis (TB) care to those infected with HIV and TB. To ensure that appropriate care is available to these

individuals, a well-functioning and well-supported TB program is essential. PEPFAR works in close collaboration with both the

Global Fund (GF) and the TB Control Assistance Program (TBCAP) which support DOTS program strengthening, essential to

good HIV-TB care. TBCAP is funded through both PEPFAR and Child Survival and Health (CSH) TB funds. Current GF activities

focus on strengthening the National TB Control Program (NTCP) through supportive supervision, drug resistance monitoring,

facility renovation, the Communication for Behavioral Intervention (COMBI) communication and social mobilization campaign, and

national expansion of cost-effective community-based care. TBCAP resources have also been used to complement GF support in

order to attain national coverage of essential TB interventions. TBCAP also focuses on fortifying the management capacity of the

NTCP through training and staff support, expansion of TB control and infection control strategies, and community mobilization and

education. PEPFAR builds on this foundation by addressing particular issues among those who are dually infected with HIV and

TB, and provides essential funding and technical assistance to strengthen laboratory capacity for TB.

According to the 2007/2008 NTCP Annual Report, Namibia reported 15,244 patients with all forms of TB, translating to a Case

Notification Rate (CNR) of 722 per 100,000 population in 2007. This CNR is the second highest in the world, after Swaziland

(WHO TB report 2007). Erongo, Hardap, Karas and Oshikoto regions had CNRs of 1,000 and above.

Also according to the NTCP 2007/2008 Annual Report, the national treatment success rate increased from 70% in the cohort

started on treatment in 2004 to 76% in the cohort of 2006. The defaulter rate declined from 13% to eight 8% in the same period.

The death rate declined from 8% to 7% and transfer out rate decreased from 7% to 6%.

Coordination between TB and HIV programs is exemplified by TB patient testing for HIV through provider initiated testing and

counseling (PITC), which has continued to increase over the years. Fifty-four percent (54%) of TB patients had known HIV status

in 2007, compared to 30% in 2006 and 16% percent in 2005. Fifty-nine percent (59%) of TB patients tested for HIV were HIV

positive in 2007 compared to 67% percent in 2006.

COP 09 resources will complement the activities supported by the Global Fund and TBCAP support by ensuring the integration of

HIV/TB training, basic community-level TB/HIV care, and community DOTS within USG-supported community and home-based

care programs. With COP 09 support, TB/HIV curricula and training programs will be standardized at the community and home

based care levels.

Namibia is in the process of strengthening TB-HIV collaboration on the national, regional, district, and clinic level. In 2008,

Namibia revived the National TB-HIV Coordinating Committee, the core role of which is to enhance collaboration between the

national TB and HIV programs. One of the identified priorities for this committee is to collaborate on the implementation of "3 Is,"

as identified by WHO. The 3 Is include intensified case finding, isoniazid preventive therapy, and infection control.

Intensified Case Finding activities will be supported in COP 09, enhancing the current Namibian HIV guidelines that recommend

TB screening for all patients in HIV care and treatment settings. Support will be provided to encourage use of clinical

management protocols that include specific screening questions related to TB in HIV care and treatment settings. The extent of

TB screening in HIV settings has been difficult to assess because of variable documentation. In PEPFAR-supported HIVQUAL

sites these data are routinely captured. Through experience gained through HIVQUAL, partners will be supported to appropriately

collect the necessary data.

MOHSS will expand TB case finding in HIV home-based care and treatment settings, as well as VCT settings. Some VCT clients

are currently screened for TB using a five question screening tool; however, there is no documentation system to capture these

data. In COP 09, data systems will be developed and implemented to capture TB screening in VCT settings. In addition, a health

care facility based case management program initiated with COP 08 funds will strengthen HIV and TB referrals for co-infected

persons and their partners.

In addition, Community based partners (i.e. Catholic AIDS Action) will use TB screening questions in home-based care settings to

identify TB suspects whom they will refer to facilities for TB diagnosis. These organizations will also have dialogue with facilities to

ensure seamless referral of clients to facilities as well as from facilities to communities.

Isoniazid Preventive Treatment (IPT) is currently emphasized in the TB and HIV guidelines in Namibia. In 2007, 4,257 PLWHA

received IPT. In 2009, the TB program will conduct an extensive evaluation of the IPT program to identify strengths and

weaknesses, and improve roll-out and evaluation of the program nationwide. In the Oshakati District Hospital, the HIV Case

Management Unit has established "Pre-ART" clinics. In this setting, health care workers concentrate on the roll-out of IPT

services. Uptake and completion of IPT services in the Pre-ART clinic has been more successful than in other settings. The

MOHSS is interested in expanding this model to other TB-HIV high burden areas of Namibia with COP 09 support.

Infection control

In 2007 and 2008, the MOHSS requested infection control consultation and assessment visits from CDC Atlanta, KNCV and

WHO. The majority of the assessments took place in TB care and treatment settings, with a primary focus of preventing the

spread of X/MDR TB. In 2009, MOHSS will implement recommendations to improve infection control measures in TB care and

treatment settings. COP 09 funds will also support expansion of necessary infection control practices (ICP) in health care settings

such as provision of respirators and masks to HCW and masks to TB patients. COP 09 will fund supportive supervision and

implementation of facility-based nosocomial transmission guidelines. TB-related ICP will be integrated with MOHSS infection

control guidelines.

The MOHSS is also committed to improving infection control in HIV care and treatment settings as well. The TB and HIV

program will work closely with the MOHSS Quality Assurance Division to strengthen the following:

• Finalization of infection control policies and guidelines

• Development and implementation of standard operating procedures for infection control in TB HIV care and treatment settings

• Strengthening of the human resource capacity through ongoing training and supervision

• Provision of additional international infection control technical assistance

• Continual assessment and upgrades (renovations) of health care facilities to meet international standards for infection control

• Implementation of health care worker screening programs

Surveillance for and management of drug-resistant 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. In addition, in 2008, the MOHSS conducted a TB drug

resistance survey with global Fund resources. In COP 09, PEPFAR will support a follow-up TB drug resistance survey.

Few health facilities are equipped to deal with the new challenge of X/MDR TB, especially with regard to the medical management

of these patients and implementation of infection control practices. With PEPFAR support, the MOHSS is developing and

implementing a comprehensive X/MDR TB rapid response plan in Namibia based on recommendations from several consultations

and technical assistance visits on X/MDR TB in 2008 from South Africa, WHO, KNCV, and CDC.

The MOHSS ordered additional second line drugs to treat X/MDR TB patients, and set up an X/MDR TB Clinical Consultation

Team to advise on the management of the treatment of the X/MDR TB cases within the country. In addition, the MOHSS is in the

process of setting up eight centers of excellence within the country for the management of X/MDR TB. In 2009, the MOHSS will

continue the process of addressing treatment, infection control, and laboratory issues that the international consultations identified

as necessary to better manage and prevent X/MDR TB in Namibia.

The TB program, like all other programs in Namibia, continues to face shortages of staff. In COP09, TBCAP and Potentia will

support key positions within the Ministry's existing staff structure.

In order to prevent drug resistant TB from developing, the MOHSS, with PEPFAR support, will strengthen the coverage areas for

community-based DOTS in COP 09 by exploring the addition of community-based DOTS to existing partners such as DAPP and

Project Hope.

The NTCP recommends that all TB patients with HIV co-infection be provided with cotrimoxazole preventative therapy (CPT).

ITECH will continue training of HCWs emphasizing routine CT for TB patients; IPT, CPT, and ART for eligible TB/HIV patients

(including children); and stronger links between TB and HIV/AIDS services. Facility and community-based programs will promote

use of IPT for those eligible.

In addition, CDC and TBCAP will support training on the revised Electronic TB Register (which includes HIV data). In COP 09,

continued support to the Namibian Institute of Pathology will also ensure that the necessary infrastructure is in place to

accommodate the increased demand for diagnostic testing. Finally, MOHSS is currently exploring the possibility of enhancing

nutritional support for TB and TB-HIV patients in COP 09.

Table 3.3.12:

Funding for Care: TB/HIV (HVTB): $260,995

NEW/REPLACEMENT NARRATIVE

This activity includes three primary components: (1) continued technical support for the Electronic TB

Register (ETR), (2) partial support for salary and related personnel costs for a continuing Technical Advisor

for Laboratory Services, and (3) support for salary and related personnel costs for a TB Laboratory Advisor.

Both advisors will be assigned to the Namibia Institute of Pathology (NIP).

1. Electronic TB Register. Namibia is one of several southern Africa countries that adopted the ETR

developed by the BOTUSA Project (Botswana-CDC collaboration) in Botswana. The ETR records

information on HIV status and use of ART in TB/HIV patients and is used to measure key indicators and

monitor expansion of HIV care and treatment among TB patients. The ETR is expected to further contribute

to enhancements in TB surveillance, and inform improvements in TB prevention, early detection, and

treatment. In FY 2009 COP, CDC will continue to support the Ministry of Health and Human

Services' (MOHSS) ongoing implementation of the ETR through a local contract with WAMTech of South

Africa. WAMTech is the sole provider of ETR software and support.

The provision of accurate data and tools for surveillance, program management and supervision has

become increasingly essential. The ETR was developed to provide more efficient and useful collection,

compilation, and analysis of TB data on an ongoing basis. The register is a Microsoft.net based computer

software program that was developed using the World Health Organization (WHO) and International Union

Against TB and Lung Disease recording and reporting formats. Many features of the ETR are derived from

a TB surveillance project in southern Africa supported by USAID and CDC Headquarters in the United

States.

As of June 2008, Namibia has 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.

The MOHSS is interested in adding an X/MDR component to the ETR to enhance monitoring and

surveillance of X/MDR TB cases.

This activity leverages resources with the USAID-funded TBCAP and Global Fund support to the MOHSS.

2. Technical Advisor for Laboratory Services. The CDC/Namibia office has seconded a laboratory technical

advisor to the Namibia Institute of Pathology (NIP) since 2005. The original scope of work for this position

was to serve as a liaison between CDC, NIP, and the MOHSS to build capacity and to ensure quality for

HIV bioclinical monitoring. Since then, the technical advisor has become more involved in strengthening

NIP's capacity for TB diagnosis, including culture and DST. He has worked closely with the International

Laboratory Branch Consortium (ILBCP) to facilitate short- and long-term technical advisors to work

alongside NIP staff. This collaboration aims to build staff expertise and to upgrade the TB laboratory, with

an ultimate goal of obtaining accreditation. The laboratory technical advisor salary is reflected in HVTB

(0.20 FTE) and the HLAB Program Areas (0.80 FTE). The lab technical advisor has also provided technical

assistance for a 2008 TB drug resistance survey, and assists MOHSS and NIP with laboratory issues

related to the diagnosis and ongoing monitoring of X/MDR TB cases in Namibia.

3. TB Laboratory Advisor. FY 2009 COP funds will support an advisor to provide mentoring and on-the-job

training to NIP technologists and technicians performing TB culture and drug sensitivity testing, both at the

national and peripheral level. As is possible, this advisor will provide similar support to private laboratories

in the country.

A number of independent assessments of the TB program in Namibia have indicated that TB laboratory

services need to be improved and expanded. While short-term assistance from the ILBCP has been

beneficial, long-term assistance in this area is essential given staff turnover, the lack of attention that can

currently be given to peripheral labs, and the need to implement a comprehensive response to increasing

numbers of drug-resistant cases of TB in Namibia. In our previous COP's, this vacant position was

envisioned as a non-personal services contract. In FY 2009 COP, this position will switch from a non-PSC

to a locally employed staff (LES) position. We feel that sufficient capacity now exists within the country to

hire a Namibian, which will also reduce costs associated with the position.

The addition of an LES TB Laboratory Advisor will enhance communication, coordination, and institutional

memory between CDC and NIP over the long-term, since we expect that Namibian LES technical staff

would remain with the program for longer than the typical contract period of a non-PSC position. This

addition will also allow the senior CDC Laboratory technical advisor to focus more thoroughly on laboratory

system strengthening activities and moving key programmatic activities forward.

Special Note: In 2008, funds were identified and reprogrammed to support the development, printing, and

dissemination of TB training materials and job aids to public and private health care providers. These

materials will focus on symptom recognition, treatment regimens, HIV/TB co-infection considerations,

X/MDR TB, and adherence counseling. These materials will be disseminated to public and private health

care providers via the MOHSS, I-TECH, and the Namibia AIDS Clinicians Society. This funding will not be

continued in FY 2009 COP as the majority of costs were one-time expenses for development of these

materials. Any future printing and dissemination costs will be minimal and paid for from other MOHSS,

Global Fund, or PEPFAR funds.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16240

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16240 7974.08 HHS/Centers for US Centers for 7390 1157.08 $333,750

Disease Control & Disease Control

Prevention and Prevention

7974 7974.07 HHS/Centers for US Centers for 4389 1157.07 $175,000

Disease Control & Disease Control

Prevention and Prevention

Emphasis Areas

Health-related Wraparound Programs

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $160,995

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.12:

Funding for Prevention: HIV Testing and Counseling (HVCT): $297,900

NEW/REPLACEMENT NARRATIVE

This area includes one component: Salary and related personnel costs for CDC's Counseling and Testing

Technical Advisor.

Since 2005, PEPFAR has funded a technical advisor to assist the Ministry of Health and Social

Services' (MOHSS) National Counseling and Testing Coordinator via a non personal services contract. By

FY 2009 COP, this position will be converted to a personal services contract (PSC). While this conversion

will increase costs somewhat, it is necessary for two primary reasons:

(1) to reflect the inherently governmental functions of these positions, and

(2) to rectify the double taxation of these positions by both the US and Namibian governments. The double

taxation results from the lack of a ratified bilateral agreement between the two countries that covers non-

PSC positions. While reducing taxation costs, this conversion will result in increased ICASS costs.

The CT Technical Advisor has and will continue to play a key role in the deployment of community

counselors to public health facilities, outreach teams, and correctional facilities. MOHSS established the

community counselor cadre in 2004 to assist doctors and nurses with provision of HIV prevention, care, and

treatment services, most importantly by providing HIV counseling and testing (CT) services to PMTCT, TB,

and STI patients as well as to partners of persons on ART whose HIV status is unknown. CCs are further

trained to provide adherence, supportive, and STI/TB counseling, as well as to link and refer patients from

health care delivery sites to community HIV/AIDS and TB services.

With FY 2008 COP support, the number of CCs will increase to 650 by December 2008. New initiatives will

place CCs in correctional facilities in 2008 and on outreach teams in 2009. Policy development, quality

assurance, and support to field services are important aspects of the technical advisor position. The

advisor will continue to provide technical assistance to the head of the Counseling and Testing Unit within

MOHSS' Directorate of Special Programmes to increase access to CT services and provider-initiated

testing and counseling (PITC) in the clinical setting.

The advisor will also guide the national program in the continued implementation of national CT guidelines

and will support the regions and districts in implementation and monitoring of program effectiveness. He

will continue to support the unit with the roll-out and supervision of counseling and testing sites in health

facilities, correctional facilities, and newly-initiated outreach teams.

Each MOHSS outreach team will consist of a camper van; four community counselors (two to provide

counseling and testing and two to coordinate logistics and supplies); a nurse; and a driver. Teams will use

community input to develop a monthly schedule of visits to remote communities. The date of visits to each

community will be kept consistent (e.g. the first Thursday of each month) so that there will be minimal

confusion about where and when the team will visit.

For each outreach team, CT services and prevention education will be implemented first. The advisor will

assist with implementation as well as a concurrent evaluation program. The evaluation program will be put

in place to determine cost per client, success in reaching first-time testers, coordination between the

outreach teams and community partners, community receptiveness, and success in linking HIV-positive

clients to care and treatment services.

The advisor further plays a key role in the recruitment, training, and allocation of CCs for CT services and to

support other programmatic areas, including PMTCT, AB, condoms/other prevention, TB/HIV, and care and

treatment services. Within ART sites, CCs provide adherence and couples counseling, among other

responsibilities. The advisor will be intimately involved with CDC advisors in the MOHSS' continuing

implementation of the prevention with positives initiative at the national level.

Lastly, the technical advisor will continue to serve as the co-chair of the National HIV Testing Day (NTD)

steering committee. This event was first held in 2008 with the goal of expanding access to CT. Using

outreach points and expanded hours, over 33,000 persons were tested over the course of the three-day

event. Of those who tested, nearly two-thirds were first-time testers. The advisor will continue to play a key

role in NTD planning and implementation, as well as similar testing events coordinated with World AIDS

Day.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $297,900

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.14:

Funding for Laboratory Infrastructure (HLAB): $272,320

NEW/REPLACEMENT NARRATIVE

In a continuation from COP08, this activity will provide funding for 0.7 FTE for a laboratory scientist

seconded to the Namibia Institute of Pathology (NIP) by CDC. To reflect the TB responsibilities of this

position, the remaining 0.3 FTE is funded through the HVTB program area.

The laboratory scientist provides support to NIP for strengthening HIV diagnosis in young infants,

introducing HIV incidence testing into routine antenatal surveillance, continuing surveillance for HIV drug-

resistance, improving TB diagnosis and quality assurance. Since FY05, CDC has placed a laboratory

scientist at NIP as a technical advisor (TA) to help develop and implement standard operating procedures to

ensure quality services related to diagnostic DNA PCR, CD4, HIV incidence testing, and resistance testing.

During FY05, the diagnostic algorithm for pediatric diagnosis using PCR was developed and the use of

dried blood spots (DBS) was field-tested. During FY06, in collaboration with the Ministry of Health and

Social Services (MOHSS) PMTCT program, the diagnostic DNA PCR was introduced for symptomatic

infants and HIV-exposed infants at six weeks of age. The TA played a focal role in ensuring that

technicians at the central and peripheral NIP labs were trained in PCR, new equipment was purchased, and

health workers were trained in the collection of dried blood spots.

The TA will continue to work with the International Laboratory Branch Consortium to coordinate ongoing

information sharing between NIP and other laboratories. These continuous quality improvement activities

will focus on laboratory management, logistics, strategic planning, and technical training, with a particular

emphasis on TB diagnostics. During FY07, the Association of Public Health Laboratories collaborated with

NIP to follow up the management training with strategic planning efforts. In COP09, the TA will continue to

work with the NIP and the MOHSS to improve turnaround times between specimen collection and receipt of

test results by expanding placement of NIP's Meditech lab information system in all ART sites and

decentralizing testing to peripheral areas through expanded use of point of care equipment. The TA will

also continue to provide assistance to NIP for program reporting.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $272,320

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.16:

Funding for Strategic Information (HVSI): $1,518,700

NEW/REPLACEMENT NARRATIVE

This activity has four main components, three of which are continuing: (1) support local costs for data

triangulation activity; (2) office support for SI-related ePMS/HIS and CDC; (3) three technical advisors, and

(4) prison HIV prevalence survey (new):

1. Local data triangulation funds: These funds will contribute to the data triangulation exercises by

supporting local costs to host the stakeholders' workshops, bringing in the regional data analysts and

officers to participate and learn, and to fund local staff travel for data analysis training. (This activity is

further described in the I-TECH HVSI narrative).

2. ePMS/HIS and CDC SI support:

This component relates to the USG-supported SI technical advisors and includes: data and monitoring and

evaluation (M&E) personnel supported through Potentia; equipment and communications supported through

the Ministry of Health and Social Services (MOHSS); training supported through I-TECH; and support to the

TB and ART information systems.

- Technical support for software applications: Namibia has adopted or developed information systems for

both ART and TB that are separate from the routine Health Information System. These systems are patient

-based (with one record per patient per encounter) and hence are more complex than the aggregate

systems maintained for routine program information. This activity will support technical assistance to help

maintain these systems in the form of training on the software, technical and supportive supervision to

newly rolled-out sites, database management, consultants for updating and reprogramming the software

based on feedback, and protocol revisions (e.g. new changes to ART guidelines).

-Regional Support Visits: SI personnel will visit the field periodically to support and supervise activities with

an emphasis on capacity building. USG will support visits by the response monitoring and evaluation

(RM&E) Unit to visit all regions and districts during FY 2009.

-Software support and training: This is to ensure that all CDC staff members that need to use an appropriate

statistical package (SPSS, SAS, STATA, etc) have updated licenses and training to be able to use the

software to enhance the programs on which they work.

3. Support for three technical advisors (M& E, HMIS, SI): The three SI Technical Advisors to the MOHSS

are an integral part of the USG SI program. The MOHSS M&E unit responsible for all monitoring and

evaluation is currently undergoing reorganization. In response to any resulting changes, CDC will refine the

duties of the three TA positions accordingly.

The first position is a Monitoring and Evaluation Technical Advisor position seconded to the MOHSS RM&E

subdivision. The subdivision had requested an epidemiologist to advise on program evaluation,

surveillance activities, research, and operations research. The second position is a Health Information

Systems Technical Advisor seconded to the MOHSS to advise on and help manage all health information

systems for PEPFAR-supported health sector programs (ART, PMTCT, VCT, pharmacy, and lab). The third

position is a Strategic Information/M&E Advisor that sits within the MOHSS and CDC and advises on routine

program monitoring, program evaluation, data capture and tool development, data triangulation, HIVQual,

costing, PEFPAR-related SI, and other special SI projects.

In the past these positions have been funded through a contract with Comforce, but by FY2009COP they

will be funded as Personal Service Contractors (PSC) in line with current CDC strategic planning.

4) Prison HIV prevalence survey:

The HIV/AIDS Program in the Government of Namibia's Department of Prison Services, Ministry of Safety

and Security has asked CDC Namibia to provide technical assistance in conducting an HIV prevalence

study in the national prison system. Although voluntary HIV counseling and testing is currently offered to

the incarcerated population and prison staff, there is varied delivery and uptake of these services. At

present, the rate of HIV infection among prisoners is unknown. Prisoners likely represent a population in

Namibia with an increased vulnerability to HIV infection, and therefore assessing the current impact of

HIV/AIDS in prisons could help to improve the health of infected inmates by increasing linkages to medical

and social services. In addition, an assessment of potential routes of HIV transmission in prisons will help

to inform the development of prison HIV/AIDS programs and serve as an advocacy tool for HIV/AIDS-

related prison policy. The survey will be conducted in six Namibian prisons, and will include HIV testing as

well as assessment of risk behaviors.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16242

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16242 3859.08 HHS/Centers for US Centers for 7390 1157.08 $345,012

Disease Control & Disease Control

Prevention and Prevention

7359 3859.07 HHS/Centers for US Centers for 4389 1157.07 $946,951

Disease Control & Disease Control

Prevention and Prevention

3859 3859.06 HHS/Centers for US Centers for 3128 1157.06 $337,567

Disease Control & Disease Control

Prevention and Prevention

Emphasis Areas

Gender

* Addressing male norms and behaviors

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $350,000

Public Health Evaluation

Estimated amount of funding that is planned for Public Health Evaluation $0

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.17:

Funding for Management and Operations (HVMS): $0

NEW/REPLACEMENT NARRATIVE

In 2009, funding will be reprogrammed from the CDC mechanism in HVMS to pay approximately $493,605

in ICASS costs to State.

This activity consists of one component: ICASS charges for the CDC Office in Namibia.

(1) ICASS. This activity further supports the International Cooperative Administrative Support Services

(ICASS) provided through the US Embassy by the Department of State. The CDC office is relatively small

and has traditionally been heavily staffed by persons in technical positions to support the MOHSS and other

partners to provide HIV prevention, care and treatment services. As a result, the CDC office has not had

the capacity to perform many of the traditional ICASS responsibilities, including travel and procurement, and

opted to subscribe for most of the services available through ICASS. When possible and cost effective, the

CDC office has and will continue to take on more of these duties in-house.

Costs here are based on an approximation that CDC's ICASS costs will increase by at least 66%. By

COP09, the following positions and one new position (Technical Advisor for Infection Control and

Communicable Disease Surveillance) will have been converted from non personnel services contracts (non-

PSC) to personnel services contracts (PSC) and will be factored into ICASS charges:

Contracted personnel include technical advisors who specialize in:

a. Health Information Systems

b. PMTCT

c. Counseling and Testing

d. Monitoring and Evaluation

e. Strategic Information

f. Laboratory Services

g. Clinical Quality Assurance

This conversion from non-PSCs to PSCs is necessary for two primary reasons: (1) to reflect the inherently

governmental functions of these positions, and (2) to rectify the double taxation of these positions by both

the US and Namibian governments. The double taxation results from the lack of a ratified bilateral

agreement between the two countries that covers non-PSC positions. While reducing taxation costs, this

conversion will result in increased ICASS costs. An individual agency's ICASS charges are based on a

complex formula of number of employees, their family sizes, workload counts, as well as the ICASS

charges borne out by other US government agencies at post. For that reason, only an estimation of CDC's

eventual 2009 ICASS charges are possible at this time.

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.19:

Funding for Management and Operations (HVMS): $1,932,451

NEW/REPLACEMENT NARRATIVE

This activity is comprised of three components: (1) salaries and personnel costs for CDC staff in Namibia.

These positions include administrative support staff as well as technical staff working in three or more

program areas, (2) operating expenses for the CDC office, and (3) ICASS costs.

Funding for this activity is divided and the remainder has been reflected in a separate entry for CDC HVMS

(base).

(1) CDC Staff. Since 2002, the CDC staff in Namibia has been located in the Directorate of Special

Programs (TB, HIV/AIDS, and malaria), Ministry of Health and Social Services. CDC direct hire personnel

include:

a. Country Director,

b. Deputy Director of Operations,

c. Deputy Director of Programs,

d. Prevention Advisor,

e. Public Health Evaluation Advisor, and

f. Health Communications Specialist.

This activity relates directly to all CDC activities and to all USG activities as part of the PEPFAR team in

Namibia. In 2002, CDC's Global AIDS Program began its collaboration with Namibia by opening an office in

the MOHSS DSP to provide technical assistance in PMTCT, VCT, TB/HIV, surveillance, and ART/care

services.

The Country Director's efforts are primarily spent assisting the DSP Director and Deputy Director with

capacity building, including the development of national technical policies and guidelines, strategic planning

for the rollout of new services, work plans for the Directorate, and field guidance and support. To date, the

DSP has been supported to develop:

• ART, PMTCT, and TB/HIV guidelines and a national rollout plan for these services;

• Guidelines for the selection of community counselors to provide CT in the clinical setting;

• Rapid HIV testing policies;

• HMIS for PMTCT and ART;

• HIV sentinel surveillance procedures;

• Procedures for providing support visits to all ART sites; and

• Guidelines on delivery of outreach services.

The Deputy Director of Programs position is currently vacant and unlikely to be filled before early 2009.

Upon their arrival in Namibia, the incumbent will continue to spend most of his or her time working with the

Ministry of Health and Social Services (MOHSS) Directorate of Special Programmes (DSP) and the

Directorate of Primary Health Care (PHC) to establish and rollout guidelines and policies and to provide field

support.

The emphasis during FY09 will include training providers on the newly updated ART, PMTCT and STI

guidelines; expanding and evaluating prevention efforts; ongoing rollout of ART services to clinics and

health centers; strengthening the ARV regimen for PMTCT; integration of TB and HIV services; developing

surveillance systems; strengthening task shifting and IMAI; improving palliative care and pediatric treatment;

introducing an incidence assay into HIV sentinel surveillance; continuing to assist with DSP's response to

drug-resistant TB; carrying out ongoing surveillance for drug-resistant HIV and TB; accelerating the rollout

of rapid HIV testing and the community counselors program; implementation of mobile services; and further

coordination of efforts and resources with the Global Fund and other donor organizations.

While primarily assisting the MOHSS with technical assistance, both the director and deputy director

provide some technical assistance related to policy development and capacity building to local

organizations, including Development Aid People to People, the Namibia Institute of Pathology, and the

Blood Transfusion Service of Namibia (NAMBTS).

In addition to direct hire staff, the CDC/Namibia office is further comprised of contracted personnel serving

as technical advisors who are specialists in:

a. Health Information Systems,

b. PMTCT,

c. Counseling and Testing,

d. Monitoring and Evaluation,

e. Strategic Information,

f. Laboratory Services, and

g. Clinical Quality Assurance.

By COP09, these positions and one new position (Technical Advisor for Infection Control and

Communicable Disease Surveillance) will have been converted from non personnel services contracts (non-

PSC) to personnel services contracts (PSC). This conversion is necessary for two primary reasons: (1) to

reflect the inherently governmental functions of these positions, and (2) to rectify the double taxation of

these positions by both the US and Namibian governments. The double taxation results from the lack of a

ratified bilateral agreement between the two countries that covers non-PSC positions. While reducing

taxation costs, this conversion will result in increased ICASS costs.

COP09 will also continue to support one Association of Schools of Public Health (ASPH) fellow providing

support in strategic information or management and administration. Locally employed staff (LES) positions

include two nurse HIV field coordinators who head up the CDC/Oshakati office, one TB laboratory

specialist, and one palliative care coordinator. Other LES positions include an office manager, a financial

analyst, two systems administrators, an administrative assistant, three drivers, two driver/administrators

(Windhoek and Oshakati offices), and a receptionist. The salaries and benefits of technical and

Activity Narrative: programmatic staff are assigned to the appropriate program area within the Emergency Plan categories, but

their management and support costs are included under this activity. The Country Director spends

approximately 40% of his time on assisting the MOHSS with policy and capacity-building, but all costs for

this position are included in this activity. The Deputy Director of Operations, the Health Communications

Specialist, the Infection Control/Surveillance Advisor, and the ASPH fellow are 100% assigned to

management and staffing.

(2) Operating expenses. Being located in the Ministry of Health and Social Services, the CDC office

provides direct logistical and material support to the MOHSS' daily programmatic operations and to

prevention, care and treatment sites in the regions. Operations costs outside of human resources include

information technology and digital videoconferencing facilities; telecommunications; photocopying and

materials production; printing of guidelines, reports, training curricula, and HMIS records; office

consumables; utilities; office maintenance and equipment; security; staff training; field, conference, and

meeting travel; and other daily operations costs.

As of COP08, a major accomplishment has been to program 90% of CDC-managed funds to partners.

Seventy-three percent (73%) of CDC-managed funds go to Namibian partners. From this office, the deputy

director of operations, office manager/financial analyst, and ASPH fellows liaise with the Program and

Grants Office at CDC-Atlanta and provide direct financial management support to counterparts in these

Namibian organizations receiving direct USG funding under Cooperative Agreements. These organizations

include the Ministry of Health and Social Services, Namibia Institute of Pathology, Potentia Namibia

Recruitment Consultancy, and Development Aid People to People. In addition to the US Embassy

procurement and financial management staff, the deputy director of operations also works closely with the

Ministry of Works and MOHSS' Directorate of Public Policy and Human Capacity Development on

renovations at ART/PMTCT sites that are contracted under the Regional Procurement and Services Office

(RPSO) in Frankfurt.

This activity leverages resources with the Global Fund, the UN Family, and GTZ which provide technical

advisors to increase capacity of the Directorates of Special Progammes and Primary Health Care, as well

as Regional and Constituency AIDS Coordination Committees (RACOCs and CACOCs).

All but three of the CDC positions in Namibia are based in the Directorate of Special Programs (TB,

HIV/AIDS, and Malaria), Ministry of Health and Social Services (MOHSS) in Windhoek, the centrally located

capital. Three additional staff members are deployed to the CDC office located on the grounds of the

MOHSS' Oshakati State Hospital located in the large northern city of Oshakati. By the end of FY08, the two

CDC/Namibia offices will consist of six CDC direct hires, eight contractors in technical roles, two locally

employed staff (LES) in technical roles, and eight LES in administrative support positions.

(3) ICASS. This activity further supports the International Cooperative Administrative Support Services

(ICASS) provided through the US Embassy by the Department of State. The CDC office is relatively small

and has traditionally been heavily staffed by persons in technical positions to support the MOHSS and other

partners to provide HIV prevention, care and treatment services. As a result, the CDC office has not had

the capacity to perform many of the traditional ICASS responsibilities, including travel and procurement, and

opted to subscribe for most of the services available through ICASS. When possible and cost effective, the

CDC office has and will continue to take on more of these duties in-house.

New/Continuing Activity: Continuing Activity

Continuing Activity: 18908

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

18908 18908.08 HHS/Centers for US Centers for 7390 1157.08 $1,072,282

Disease Control & Disease Control

Prevention and Prevention

Table 3.3.19:

Cross Cutting Budget Categories and Known Amounts Total: $2,512,416
Human Resources for Health $559,448
Human Resources for Health $226,885
Human Resources for Health $75,000
Human Resources for Health $75,000
Human Resources for Health $444,073
Human Resources for Health $25,000
Human Resources for Health $25,795
Human Resources for Health $160,995
Human Resources for Health $297,900
Human Resources for Health $272,320
Human Resources for Health $350,000
Public Health Evaluation $0