NEW/REPLACEMENT NARRATIVE

For the first three years of FABRIC beginning in 2005, FHI's main partner in Namibia was the Church

Alliance for Orphans (CAFO), to which it has successfully provided capacity building, training, policy

formulation and support for small grants to local congregations and Faith Based Organizations (FBOs). In

turn, these sub-grantees (in 7 regions of the country) provided direct care and support to over 3000

Orphans and Vulnerable Children (OVC). CAFO has since graduated into direct funding under the New

Partners Initiatives (NPI). Hence, in FY 2008 COP, FHI/FABRIC began working with Positive Vibes, an

organization largely comprised of PLWHA, as their new FABRIC Implementing Agency (IA) for Namibia.

Prior to its engagement with FHI/FABRIC, Positive Vibes implemented the Children's Voices project, which

builds on experimental learning and communication techniques for children living with and directly affected

by HIV/AIDS, on a pilot basis. During its first year of operation under FHI/FABRIC, Positive Vibes aimed to

provide quality services and care to 2500 OVC (500 directly and 2,000 indirectly) in the Omusati, Oshana,

Ohangwena, Oshikoto and possibly the Khomas and Karas geographical areas. The start up phase

included a needs assessment by piggy-backing on a Treatment Literacy Survey that was planned by

Positive Vibes with the Social Marketing Association, NawaLife, the Rainbow Project, FHI, and Catholic

AIDS Action.

Positive Vibes aims to once again serve 500 OVC directly and 3000 indirectly in its second year, which will

operate on carry-over funds from FY 2008 COP and last through May 2010. As in the first year, 220

parents, caregivers and staff from partner organizations will be trained. It is hoped that most facilitators who

were trained under FY 2008 COP will still be available, but some new facilitators will still need to be trained,

especially for regions of the country that had not previously been covered.

The goal of the Children's Voices project is to give the children the confidence, opportunity and life skills

with which to access needed services and make good decisions for the future. The project uses psycho-

social support as its core service, and then adds legal protection training (e.g. child rights), and health

education (e.g. HIV prevention, disclosure, testing and treatment) with referrals and follow-ups for children

in need of additional assistance, especially those who are HIV+, eligible for government social welfare

grants, and/or in need of protection from abuse and the abrogation of rights. Additionally, the project works

with adult relatives, community leaders (including local clergy, church elders and FBOs), and national-level

stakeholders to train them in the methods pioneered by Positive Vibes.

Through this approach, targeted children in this project (i.e. the children of PLWHA members and

caregivers in 53 support groups, their siblings and peers, plus the children associated with partner

organizations) will access quality, community-level services at four levels, via:

1. Direct service: Positive Vibes will provide the children with psychosocial support, health education and

legal protection through its Children's Voices methodologies. Children will also have the opportunity to

engage in an "empowerment project" where they take what they have learned and share it with others in the

community via drama, posters, media (if available) and other outreach activities.

2. Services accessed in the community: through Positive Vibes modules and subsequent follow-up activities

(which will be identified, designed and implemented by the children under the guidance of trained facilitators

and support group members), the project will provide the participating OVC with a platform to access and,

where necessary, advocate for improved social, welfare and legal services.

3. Training of OVC Parents and Caregivers; indirect services to OVC will be reinforced by working in parallel

with the OVC parents and guardians, thereby preparing and assisting the adults to respond to the needs

identified by their children through the Children's Voices activities;

4. Additional training and indirect services from FBOs and other service providers; Positive Vibes will also

enhance the capacity of those responsible for providing pastoral care and other services to OVC under their

care - e.g. FBOs, religious leaders, teachers, formal health and home-based care workers, and government

social workers.

With FHI/FABRIC's assistance, Positive Vibes will work towards improving the quality of services provided

to OVC in line with the QA standards adopted from the Ministry of Gender Equality and Child Welfare. In

this second year, up to 70 local facilitators and 220 caregivers and agency-staff (from partner organizations)

will be trained in some of the methods employed by Positive Vibes, such as AIDS & Me, Body Mapping,

Tree of Life, Hero-Books, and the promotion of child-empowerment projects. It is hoped that there will be

sufficient local facilitators from the first year to conduct all second-year activities, but if that is not the case

then the budget will be adjusted or additional funding will be sought to provide additional training and

mentorship support from the lead facilitator/s.

In FY 2008 COP, FHI/FABRIC began its capacity-building relationship with Positive Vibes through the

TOCAT organizational assessment, in order to strengthen Positive Vibes' ability to implement, monitor and

evaluate the project's activities, thereby ensuring that the quality of training, facilitation and implementation

is maintained and that the necessary reporting requirements are met. This was with dual aim that: a)

Positive Vibes can develop a group of community-based Children's Voices facilitators who can continue

carrying out these methods in the future, and b) Positive Vibes will gain the administrative capacity and

financial resources to scale up the project (directly or through partners) throughout the country. This

process is expected to continue in FY 2009 COP.

FHI has hired a full-time Technical Officer to assist Positive Vibes in its management, technical,

programmatic and community roles. Furthermore, in FY 2008 COP FABRIC requested an extension of the

funding granted for October 2008-September 2009 for a 20 month period (at no extra cost - until 31 May

2010) in order to extend direct services to 500 OVC in each year (i.e. 500 + 500), train 440 caregivers,

reach a total of 5000 children indirectly.

Activity Narrative: Positive Vibes will continue to advocate for the greater involvement of HIV-positive people (adults and

children) from participating support groups, area networks and community-based forums. Within this

context, FHI/FABRIC will support the continued distribution and use of a new curriculum on Counseling

HIV+ Children that was drafted and tested in conjunction with Catholic Health Services and Lifeline-

Childline, with the approval of MoHSS. Finally, FHI/FABRIC will assist Positive Vibes in its linkages with

government agencies, Community AIDS Co-ordinating Committees (RACOCS and CACOCS), and non-

governmental AIDS service organizations such as Yelula-Ukhai, the Social Marketing Association, CAFO,

and Catholic AIDS ACTION.

In FY 2009 COP FHI/FABRIC and Positive Vibes will ensure quality of care and services to OVC through a

rigorous Monitoring and Evaluation (M&E) system that will culminate with a national gathering of the

organization's participants to disseminate "lessons learned." Furthermore, plans will be undertaken in FY

2009 COP to help Positive Vibes achieve long-term sustainability through direct funding with USAID and/or

other donors. Finally, FHI/FABRIC and Positive Vibes will work to ensure that the methodologies and

lessons-learned through the project are continued with little or no outside support at the community level

wherever the project has been able to provide services. In the final months of the FABRIC project (June

until mid-August 2010), FHI will work on the FABRIC close-out and write the final report.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16125

Continued Associated Activity Information

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

System ID System ID

16125 3780.08 U.S. Agency for Family Health 7358 1575.08 Track 1 $530,446

International International

Development

7401 3780.07 U.S. Agency for Family Health 4404 1575.07 Track 1 $218,797

International International

Development

3780 3780.06 U.S. Agency for Family Health 3068 1575.06 Track 1 $333,563

International International

Development

Emphasis Areas

Health-related Wraparound Programs

* Child Survival Activities

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 14 - HVCT Prevention: Counseling and Testing

Total Planned Funding for Program Budget Code: $10,928,270

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Namibia has a well established, functional HIV testing program. According to the Namibia Demographic and Health Survey

(NDHS) of 2006/2007, among people aged 15-49, 87% of men and 92% of women knew where one could get an HIV test.

Among women, 45% have ever been tested for HIV while 29% reported being tested in the 12 months preceding the interview.

For men, 32% had ever been tested while 18% were tested in the 12 months preceding the interview. These data from the NDHS

indicate men are less likely than women to be tested, a trend that is observed in the Annual Progress Reports (APRs) since 2004.

Namibia's HIV testing program also includes testing in PMTCT settings. Two years preceding the NDHS survey, 73% of women

who gave birth received HIV counseling during antenatal care for their most recent birth. Nearly all women tested received their

results. According to the National HIV sentinel survey of 2006, HIV prevalence among pregnant women was 19.9%. Data for the

2008 survey are being analyzed. Using the spectrum model, adult National HIV prevalence is estimated to be 15.3%.

Given the high HIV prevalence, the government of Namibia has prioritized intervention to increase the number of individuals who

know their HIV status. The HIV testing program continues to be faced with a number of challenges including, but not limited to,

human resources, appropriate infrastructure, low couples and male uptake, and access to testing services. Two principal

approaches have been adopted for HIV testing: (1) facility-based HIV testing including client initiated and provider initiated testing

and counseling, and (2) community-based testing. The community-based component is delivered through stand alone sites (i.e.

New Start sites). In the future, a work place program will be integrating HIV testing.

Since COP04, counseling and testing (CT) activities have included technical assistance to the Ministry of Health and Social

Services (MOHSS) at the national level. The CT Technical Advisor supports the MOHSS in the development of national

guidelines, curricula and training, as well as the establishment of rapid HIV testing and quality assurance (QA). Other support to

MOHSS includes HIS support, health facility renovations, and procurement of CT test kits and consumables. Namibia's HIV

testing program has been successful in rolling out Rapid HIV Testing (RT), availing more clients to their results on the same day

of testing and allowing referral for appropriate services. In COP09, USG support will continue to enable the rollout of RT services

to more health facilities, as well as CT training for health workers.

To address the human resource constraints, the USG is also supporting a very innovative strategy of utilizing community

counselors (CCs) for the provision of CT services. The introduction of CCs in mid-2005 has been a major boost for provider-

initiated integrated CT services as well as voluntary counseling and testing in community-based centers. These CCs are

equipped to deal with clients in a wide range of settings including PMTCT, TB, STI and ART clinics, and general outpatient clinics.

CT is now routinely offered to pregnant women, TB and STI patients in hospitals, health centers, clinics, and, increasingly, to

patients with suspected HIV-related symptoms. Community counselors receive a six week didactic and six week practical training

and RT training. The CCs are certified as rapid HIV testers after performing 50 tests under supervision. Quality assurance results

for CCs thus far show nearly 100% concordance with ELISA. In COP09, refresher trainings for the deployed CCs will be

enhanced to include prevention with positives (PWP), couples counseling, and pediatric counseling, among other areas. For

COP09, costs for 650 CCs will be distributed across the following program areas: Preventing Mother to Child Transmission (7%),

Abstinence and Be Faithful (53%), Other Prevention (8%), HIV/TB (9%), Counseling and Testing (13%), and ARV Services (9%).

Namibia is characterized by long distances to health service delivery facilities with a sparse population and low number of people

ever tested for HIV. Part of the efforts to mitigate this is to take services closer to the people. In FY2008, the first ever National

HIV Testing event took place in May for three days. A total of 33,760 persons were tested and received their 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. Given the success of this occasion, COP09 funding will be used to support

promotion of two CT events, one of which will coincide with the World AIDS Day commemoration. The national testing events will

result in more people knowing their HIV status and accessing other HIV services through referral.

The National HIV Testing event was also utilized, for the first time, to test 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. After the event, the MOHSS gave approval for VCT outreach, and community-based centers have

piloted the outreach activities in combination with promotional events such as a bicycle give-away campaign with good results. As

a result of these outreach activities and a comprehensive training for site specific community mobilizers, sites with chronically low

uptake have significantly improved their client flow. In accordance with the national strategy, COP09 funding will support the

provision of pilot mobile outreach CT services, including mobile/outreach vans, related equipment, and personnel. One of the

community-based sub-partners has been graduated to direct funding and will be providing CT services under the New Start

franchise.

In COP08, the USG is providing support through IntraHealth to implement a network of 12 community-based, free-standing CT

centers and six integrated testing centers (centers within health facilities) in 10 regions. The network began in 2003 with EU

funding and six centers. Since FY05, USG funding has expanded the network to eight more centers, including the integration of

CT within PMTCT and ART programs in five MOHSS supported mission hospitals and one health center. As a result of continued

USG support for these services, the network has seen dramatic increases in client numbers; the total number of CT tests

administered rose from 13,425 in COP04, to 31,061 in COP05, 48,000 in COP06, and 66,883 in COP07. On average, more than

5,500 tests per month were administered during that year final year.

Unlike integrated HIV testing sites, stand alone or New Start facilities are sometimes faced with low uptake of services. In

COP09, USG-supported community-based testing partners will implement focused community mobilization and a behavior

change communication strategy targeting first time testers, couples, and male testing. The New Start program has trained

community mobilizers in Interpersonal Communication (IPC) to motivate clients in the neighborhood of the facilities to utilize them.

This strategy has resulted in an increased number of clients being tested in the New Start facilities. IPC activities are combined

with other promotional activities.

USG support for community-based centers is being leveraged by the Global Fund (GFATM), which has been providing funding for

a USG community-based CT partner to set up a community center at Eenhana, the first center in Ohangwena region. The

MOHSS is expanding capacity within the public sector to increase CT provision with rapid testing through decentralization at

health facilities, financed principally by the USG and the GFATM. The GFATM has also provided an assistant CT coordinator in

the MOHSS to work with the National CT Program Coordinator and the USG-funded Technical Advisor.

Challenges to CT activities include a persistent stigma toward HIV testing in some regions, which has resulted in low uptake of

testing services particularly among men. Community-based programs and integrated sites in mission hospitals have made

significant progress in increasing the number of men tested, which now stands at 42% among new testers, while the re-testing

rate has decreased to about 20%, with some centers recording only a 10% re-testing rate. Stigma of testing has been reduced

significantly by engaging communities neighboring these facilities in activities such as male conferences, community meetings,

and community presentations.

Members of the military and other uniformed forces are among the most at risk populations in Namibia. In COP06, the Namibian

Ministry of Defense, with support from the USG Department of Defense, initiated HIV testing within the military at two sites.

COP08 sites will be increased to four. In COP09, outreach services will also be added and this military program is expected to

reach about 4,000 new HIV testers.

Quality services being rendered in the HIV testing program are continuously being reviewed to assure the highest standards

possible. In this regard, the need to develop quality assurance protocols and manuals was recognized and provisions were made

to develop them in COP08. These tools will be rolled out in COP09. A QA structure headed by the CT national office (through a

QA officer based at MOHSS and regional QA officers) will be rolled out in COP09. To improve management and direction, the

New Start program will have regional supervisors who will work closely with MOHSS QA team. The Namibia Institute of

Pathology will support the laboratory quality assurance program.

In COP09, through USG support to the HIV testing program, a total of 274,000 HIV tests will be administered nationally with about

219,200 being first time testers. This will increase the number of Namibians who know their HIV status, also resulting in a greater

number of those requiring HIV treatment services.

Table 3.3.14: