This mechanism is intended to develop and build the institutional capacity of the Ministry of Defense/Namibian Defense Force (MOD/NDF),through pre- and in-service training and mentoring, to strengthen ownership, leadership, management and planning capacities and ultimately to sustain the HIV/AIDS response in the Namibian military.

The overall goal of this mechanism is to support the strategic goals and objectives of the 5 year National Strategic Framework (NSF) and the Partnership Framework Agreement (PFA) by providing comprehensive HIV care and treatment services in MOD/NDF.

1. I-TECH has five comprehensive goals under this mechanism. I-TECH assists the MOD/NDF to build capacity to: a) Expand and strengthen military counseling and testing services and promote use of these services; b) Pilot and establish male circumcision (MC) services; c) Strengthen and expand HIV treatment, care and support (including tuberculosis (TB) services and laboratory support), prevention with positives, and promote use of these services; d) Build capacity and fortify infrastructure for strategic information; and e) Strengthen health systems and enhancing human resources for health, through both in-service and pre-service capacity building and mentorship programs for military health personnel, improving the pharmacy and medicine logistics, ensuring quality laboratory services, addressing stigma and discrimination, fostering leadership and management, and supporting MOD policy initiatives.

2. I-TECH will contribute to the goals and benchmarks of the PFA and Partnership Framework Implementation Plan (PFIP) through a focus on building the MOD/NDF's capacity to create an enabling environment to effectively manage and deliver quality, accessible HIV care and treatment services. COP10 activities support the USG objectives and commitments in the following focus areas: care support and treatment; prevention, and coordination and management. Specifically, I-TECH contributes by: a) Assisting the military to tailor MOHSS service delivery systems and tools to fit the specific needs of the military, with emphasis on the establishment of quality assurance (QA) systems. Maintaining focus on building MOD/NDF capacity, including trainings structured to ensure services remain uninterrupted during the military staff rotation process, the continuation of mentoring activities, and introduction of pre-service bursaries in the most critical health areas to address the shortage of human resources for health in the military. Reflecting Namibia's long term goal to integrate antiretroviral treatment (ART) services into primary health care (PHC) settings, activities include supporting the MOD to scale up a standardized, comprehensive package of HIV services that can be expanded as tasks are shifted to the nursing level. b) Providing technical assistance and equipment/supplies to support the military to pilot and scale-up MC services. c) Enhancing management and leadership skills at both the facility level and the national level so that the military can ultimately take over overall planning, budgeting, management and monitoring and evaluation of the entire health system.

3. The target population is approximately 15,000 MOD/NDF staff and civilian workers at the 23 military bases and camps spread throughout the country.

4. Key contributions to health systems strengthening include support to: roll out the MOD/NDF's first sectoral HIV policy, address HIV-related stigma and discrimination, and enhance management and leadership. In addition, I-TECH works to tailor MoHSS systems to military settings in order to ensure synergies between the national program and the military program and to ensure coordination between MOD/NDF and MOHSS; strengthen QA systems; enhance physical infrastructure; and procure equipment and provider imitated testing and counseling (PITC), and MC services. To date, assistance has enabled the MOD/NDF to launch its first treatment site and to establish the first military laboratory capable of processing HIV-related tests. Technical assistance will be provided to the military in order to strengthen linkages between community based and clinic based HIV care services.

5. Cross-cutting programs and key issues. X-cutting: Human resources for health Key issues: Military population (also a mobile population and workforce program) Health Wrap around: TB and Prevention with Positives Gender: Addressing male norms and behaviors, through Positive Health Dignity and Prevention (PHDP), VCT and MC counseling

6. Highlights of activities to become more cost efficient over time include: Integrating military HIV services into services regularly provided at each clinic and sick bay, will lower the cost of providing services. Making provisions for MOD/NDF staff to participate in the MOHSS's existing training programs eliminate the need to update curricula and creates an economy of scale for the MOD.

7. The monitoring and evaluation plan includes PEPFAR indicators and is fully integrated into the overall USDOD M&E plan for assistance to the MOD/NDF. In COP10, as the country moves to a national M&E plan with aligned indicators, I-TECH will modify the M&E plan accordingly.

THIS IS A CONTINUING BUDGET CODE NARRATIVE AND HAS BEEN MODIFIED AS FOLLOWS:

This continuing activity assists the Namibian Ministry of Defense/Namibian Defence Force (MOD/NDF) contribute to the National Strategic Framework (NSF) and Partnership Framework Agreement (PFA) to strengthen community home based care and palliative care for military personnel and civilian employees working on military bases.

The budget code activity has the following three main components that will assist the MOD/NDF to: (1) expand and enhance clinic-based palliative care service delivery systems (2) strengthen and expand coverage of military support groups for persons infected with and affected by HIV, and (3) reinforce home-based palliative care.

a) To support the military to expand and enhance clinic-based palliative care service delivery systems, International training and Education Centre on HIV (I-TECH) will assist the military to develop a comprehensive package of HIV services based on national Ministry of Health and Social Services (MoHSS) and nursing board guidelines. Such HIV services could include: prevention counseling, STI screening/treatment, alcohol screening/referrals, male circumcision education/referrals, TB screening/treatment /referrals, PMTCT referrals, screening and Pre-ART treatment, prophylaxis and management of OIs, medicine adherence counseling, nutrition services, psychosocial support/referrals, screening/alleviation of HIV-related symptoms and pain, and HIV treatment and care follow-up and monitoring. In addition, positive health, dignity, and prevention (PHDP) will be rolled-out in the military in COP10. b) To support the MOD/NDF to enable four military health facilities to routinely offer this package of services, I-TECH will provide in-service training and mentoring healthcare workers in HIV comprehensive care and treatment service delivery, recording and reporting, and quality assurance. c) I-TECH will supply military sites with necessary equipment and starter stock of supplies while the MOD/NDF is preparing itself to take over the management of this budget code.

d) I-TECH will assist the MOD/NDF to strengthen existing support groups and assist the military to establish new groups. Selected military staff will be trained to assist support groups and link groups with psychosocial support. I-TECH will enable support groups to arrange for guest speakers, create an interchange of ideas among groups, as well as create a small fund for innovative support group projects. Military health care workers will be trained to educate support groups on topics such as improving medicine adherence, PHDP topics, and basic nutrition. e) I-TECH will support military healthcare workers to provide home-based palliative care, psychosocial and spiritual support, and referrals for chronically and terminally ill military staff who require home support. Military healthcare workers, and chaplains, will continue to receive training and technical support in different aspects of home-based palliative care and PHDP, as well as receive the standardized home- based care kit, which is recommended by the MoHSS to enable healthcare workers to conduct effective and quality visits.

This activity contributes to the sustainability of military HIV care and support services through capacity building of military health care workers (HCWs) and establishment and strengthening of HIV care and support systems, with a focus on quality assurance systems. Support in training and quality assurance measures are included as USG sustainability commitments in the Partnership Framework Agreement.

For all HIV care and support indicator targets, it is anticipated that all military services will be offered to adults older than 18 years of age and an estimated 85% of military clients will be male. An estimated 450 eligible adults will be provided with a minimum of one care service and 450 HIV-positive adults will receive a minimum of one clinical service. Given that national guidelines may change to a higher CD4 threshold for eligibility for both ART and CPT, an estimated 200 HIV-positive persons will receive cotrimoxazole prophylaxis. An estimated 50 HIV-positive clinically malnourished clients will be in need of therapeutic or supplementary food. These 50 clients will also be reported as the number of eligible clients who received food and/or other nutrition services.

THIS IS A CONTINUING BUDGET CODE NARRATIVE AND HAS BEEN MODIFIED AS FOLLOWS:

The goal of this continuing budget code is to strengthen the capacity of the Ministry of Defence/Namibian Defence Force (MOD/NDF) to provide high quality military HIV treatment services for military staff members and civilian employees working on military bases. This activity contributes to national objectives to increase ART coverage to 85% of adults by 2010, as well as to increase the percentage of ART clients

that are still alive after one year of treatment from to 90% by 2015.

The overall objective of this budget code is to contribute to the National Strategic Framework (NSF) and Partnership Framework Agreement (PFA) to enhance the quality of care by scaling up the pre-ART program. The four main components of this activity include assisting the MOD/NDF to: (1) expand and enhance HIV service delivery systems, including strengthen quality assurance, (2) build human capacity, and (3) increase use of military HIV treatment services.

(1) To expand and enhance HIV services, I-TECH will assist the MOD/NDF to introduce a standardized package of HIV services at four large military clinics. I-TECH will assist the MOD/NDF to establish a package of HIV services that includes screening and pre-ART treatment, adherence counseling, and treatment follow-up and monitoring. Should the task shifting process continue, and the initiation of ART be devolved to nurses, I-TECH will train military nurses to initiate ART. This potential task shifting will contribute in the long-term sustainability objective of integrating ART services into routine primary health care services.

I-TECH will assist the MOD/NDF to continue to tailor MoHSS systems, such as recording and reporting, to the specific needs and requirements of the military. Through building the capacity to record patient data and generate monthly and cohort reports, the military can more easily monitor quality of services, including rapid identification of clients who miss appointments. Additional support will be provided to military staff to monitor quality of care through case reviews.

(2) I-TECH will assist the MOD/NDF to build capacity of military health care workers (HCW) through in- service training and clinical mentoring, as well as through the participation of national and international meetings and conferences. I-TECH will train military personnel to provide ART services including, provision and management of ART, integrated management of adult and adolescent illnesses (IMAI), adherence counseling, and pharmaceutical management.

(3) To assist MOD/NDF to create demand for military HIV treatment services, I-TECH will assist the MOD/NDF to develop military behavior change initiatives, as well as to strengthen referral systems. Through the launch of the MOD/NDF's film, Remember Eliphas 3, the military can advertise new HIV services at all bases as well as encourage crucial health seeking behaviors, such as seeking care earlier in the disease process. To complement the film, I-TECH will assist the military to develop a facilitator's guide to assist military staff to conduct small group discussions after film viewings. I-TECH will continue to support the military to enhance the capacity of military Counseling and Testing (CT) sites and health facilities to effectively refer HIV-positive clients to military sites offering HIV treatment services.

This activity strengthens quality assurance (QA) by assisting the MOD/NDF to adapt Ministry of Health and Social Services (MoHSS) quality standards, providing support for monitoring patient information that reflects quality of care, initiating case review meetings, presenting options to MOD/NDF for other methods of monitoring quality and models to improve quality.

The activity contributes to the sustainability of military HIV treatment services through capacity building of military staff, and strengthening service delivery systems, with a focus on quality assurance. Support for training, quality assurance measures, and the expedition of scale-up efforts are included as USG sustainability commitments under the Partnership Framework Agreement.

It is anticipated that only adults will access military services and approximately 85% of all clients will be male. 200 adults with advanced HIV infection are expected to newly enroll in ART in COP10. This number is higher than the previous year due to a possible change in national eligibility criteria for the initiation of ART that will shift additional clients from Pre-ART to ART in COP10. Anticipated task shifting of ART initiation to registered nurses would also allow additional military bases to offer services. An estimated 270 adults with advanced HIV infection are expected to be receiving ART at the end of the FY10. 80% of adults are expected to be alive and on treatment 12 months after initiation of antiretroviral therapy. No previous data is available as military ART services were recently launched. This estimate is based on the assumption that many clients still access services late in the disease process. At military facilities, a total of 300 adults with advanced HIV-infection are expected to have ever started ART.

THIS IS A CONTINUING BUDGET CODE NARRATIVE AND HAS BEEN MODIFIED AS FOLLOWS:

This continuing budget code supports the Ministry of Defense and the Namibia Defense Force (MOD/NDF) to strengthen and expand HIV counseling and testing services under the Military Action and Prevention Program (MAPP). Military counseling and testing (CT) services contribute to national objectives by making CT service more accessible to military personnel. In addition, military personnel are primarily male, a population which is currently underutilizing CT services in the country. Prioritizing CT activities and promoting sustainability of CT services is a fundamental strategy of the MOD, PEPFAR, and the Government of Namibia as reflected in the Partnership Framework Agreement (PFA) and the National Strategic Framework (NSF).

This continuing budget code has four primary components that will assist the MOD/NDF to: (1)

strengthen existing military CT services and the health systems that support them, (2) expand services to additional military bases, (3) build the capacity of military health care workers (HCWs), and (4) increase the uptake of CT services.

1) I-TECH will assist the MOD/NDF to enhance existing CT services through strengthening quality assurance (QA) and supportive supervision, referrals, management systems, and integration with additional services and quality assurance for both CT sites and outreach services. I-TECH will continue to assist the MOD/NDF to reinforce internal and external QA systems with a focus on counseling, rapid testing, and data functions. To ensure continuous quality improvement of HCT activities across the military network and to strengthen the institutional capacity of the MOD to manage their CT services. Quarterly CT program review meetings will augment QA activities. QA for rapid testing will be supported by the MOD laboratory staff and their partnership with the Namibia Institute of Pathology (NIP). NIP will continue to certify MOD/NDF staff trained in HIV rapid testing, as well as to certify new sites. 2) I-TECH will also assist the MOD/NDF to establish quarterly CT program review meetings to analyze data and identify areas for improvement. Additional services will continue to be integrated into CT sites, such as TB screening and referrals, referrals for male circumcision, discussion of gender-based violence and male norms, positive health dignity and prevention (PHDP) for PLWHA, and alcohol use screening. Referral systems will be strengthened to ensure that clients testing positive are linked to other clinical, preventive, psychosocial and spiritual care, including PHDP clinical services. 3) Access to CT services will be extended to additional military bases, through the expansion of existing self-initiated counseling and testing, expansion of CT outreach services, and the launch of provider- initiated testing and counseling (PITC) services. Two additional CT sites will be established, military outreach CT services will be expanded to two additional bases and provider-initiated counseling and testing will be established at a minimum of six sites. 4) To build the capacity of military personnel to conduct counseling and testing services, additional military medics, counselors, and nurses will be trained to offer and promote services. CT site managers and their deputies will receive a specialized training to fortify the management of services. To encourage the further exchange of ideas, site managers will participate in supportive supervision visits to other military facilities. 5) To increase the uptake of CT services, I-TECH will assist the MOD/NDF to develop strategies to increase self-initiated visits through annual National Testing Day(s), special campaigns, and collaborate with the MAPP prevention partner to link CT with the military's peer education network.

An uninterrupted supply of rapid tests and medical consumables for military CT services is built upon the MOD/NDF's existing arrangements with the MOHSS's Central Medical Stores.

An estimated 4,000 individuals will receive CT services and receive their test results in FY10. The uptake

of CT services is expected to increase significantly in COP10 due to the anticipated introduction of PITC, roll-out of services to additional bases, and additional demand generation activities. In the past, approximately 80% of clients tested were male, thus it is expected that 3,200 males and 800 females will receive testing in FY10. All individuals tested are expected to be 15 years of age and older.

THIS IS A CONTINUING BUDGET CODE NARRATIVE AND HAS BEEN MODIFIED AS FOLLOWS:

The goal of this continuing budget code narrative is to build the capacity of the Ministry of Defense/Namibian Defense Force (MOD/NDF) in strategic information, including the ability to gather and analyze service delivery and survey data, utilize data to improve the quality of care, and to strategically plan in response to evolving needs, programmatic innovations, and new technologies. This activity supports the National Strategic Framework (NSF) and the Partnership Framework Implementation Plan (PFIP) for national scale-up and sustainability of services in Namibia.

This budget code has two main components that support the MOD/NDF to: (1) Strengthen military capacity to monitor and evaluate HIV-related services and activities and use data for continuous quality improvement, and (2) conduct an HIV sero-prevalence and behavior survey.

i.a) To strengthen the MOD/NDF's capacity to monitor and evaluate HIV-related services and activities, I- TECH will continue to: • Collaborate with the management and information (MIS) working group to guide the development of the MIS and identify military routine reporting requirements. • Develop an MIS that links HIV clinic database to pharmacy and lab databases. Create monthly and cohort report formats. • Update and customize the counseling and testing (CT) database to the specific needs of the military. • Build military staff capacity to maintain equipment and networks in a sustainable way, • Train military healthcare workers in basic computer skills and use the two databases, • Procure equipment and internet services necessary to expand computer and internet connectivity. i.b) To promote the use of data to continually improve the quality of HIV services, the MOD/NDF will be assisted to: • Generate reports on quality of care indicators that assist military health facilities to identify areas to target for improvement, such as the success of referrals, the rate of client missed appointments for care and treatment, etc.

• Conduct quarterly referral and CT program reviews. During the first few reviews, participants will review data from other sites and make recommendations to improve data collection. These reviews will evolve into the use of data to improve the quality of care and planning. • Assist the MOD to conduct Quarterly Care and Treatment Program Reviews with a proposed structure similar to the Referral and CT Reviews. • Assist MOD/NDF to evaluate access to services among military staff and civilian employees working on military bases.

ii. a) Assist the MOD/NDF to conduct an HIV sero-prevalence and behavior survey by training MOD/NDF staff and providing rapid testing kits and other supplies. I-TECH will collaborate with the military to develop the survey methodology and protocol. Twenty-five MOD/NDF staff will be trained to coordinate and implement the survey. The MOD/NDF will be supported to collect and analyze data, and generate a survey report. ii. b). Provide support to MOD/NDF to build the capacity in conducting HIV research and how to analyze and interpret data.

To foster sustainability, military healthcare workers will be enrolled in computer classes to build a foundation for further training in health management information systems and in monitoring and evaluation approaches. The activity will also build capacity of MOD/NDF information technology (IT) Specialists in systems management and hardware maintenance. In addition, the MIS working group will identify staff to work side-by-side with I-TECH staff to begin the transfer of IT support to the MOD/NDF's MAPP.

Optional indicator targets include: A minimum of thirty individuals trained in strategic information. This includes 25 military staff trained to implement the sero-prevalence survey and five military staff trained in the MIS. Additional staff to be trained in computer and network maintenance and monitoring and evaluation and research approaches will be identified by the MOD/NDF during COP10.

THIS IS A CONTINUING BUDGET CODE NARRATIVE AND HAS BEEN MODIFIED AS FOLLOWS:

This continuing budget code narrative will focus on assisting the Ministry of Defense/Namibian Defense Force (MOD/NDF) to strengthen systems and the enabling environment for implementation of the MOD/NDF's HIV Military Action and Prevention Program's (MAPP) prevention, care, and treatment

services. This budget code contributes to the National Strategic Framework (NSF) and the partnership Framework Implementation Agreement (PFA) by creating and sustaining an enabling policy and legal environment to scale-up prevention and treatment services, building on existing services and ensuring quality and equitable access to care and treatment. The activity also contributes to long term ownership and sustainability of the program by providing support in human capacity development via pre and in- service training, and enabling MOD/NDF to effectively implement the program.

This budget code is comprised of four main components, including supporting the MOD/NDF to: (1) launch the first military sectoral HIV policy, (2) reduce HIV-related stigma and discrimination, (3) build capacity of senior level military personnel through participation in study tours and/or regional and international meetings and trainings, and (4) build institutional capacity and strengthen staff management skills. Efforts will be made to improve the integration and linkages between facility-based and community- based services.

a) I-TECH will assist the MOD/NDF to launch their first sectoral HIV policy. Currently under parliamentary review, the draft policy is expected to be approved in COP10. Upon approval, I-TECH will support the MOD/NDF by translating the policy into three languages and printing 2,000 copies for dissemination to military commanders and HIV coordinators. Two workshops will be conducted for 46 commanders and their deputies to educate them on the content of the new policy and develop action plans to guide its implementation.

b) HIV-related stigma and discrimination remains a key barrier that limits access to military HIV services and hampers the well-being of people living with HIV/AIDS (PLWHA). To address this barrier, as well as to prepare commanders for the launch of the military sectoral HIV policy, I-TECH will continue to collaborate with local non-governmental organizations (NGO) to conduct HIV-related stigma and discrimination reduction trainings for 40 military commanders, unit HIV coordinators, gender focal points, chaplains, and staff involved in HIV care and support.

c) To build the capacity of senior military personnel and expose personnel to recent lessons learned in implementing HIV programs, I-TECH will facilitate the participation of military staff in study tours and/or regional and international meetings and trainings. ITECH will provide support to MOD/NDF to undertake study tours to southern Africa to strategically plan expansion of services, facilitate training in advanced M&E, or participation in the annual HIV Implementers meeting, etc.

d) To build institutional capacity and strengthen staff management skills, I-TECH will facilitate management training for MOD/NDF at the national and health care facility levels.

Indicators for this budget code include: Pre-service training in laboratory technology that will begin in COP10. Ten community health workers are expected to successfully complete a pre-service training program for lay counselors in COP10. One hundred health care workers are expected to successfully complete an in-service training program, in topics such as: palliative care, treatment, positive health, dignity and prevention/prevention with positives (PHDP/PWP), counseling and testing, prevention, male circumcision (MC), laboratory, strategic information, and systems strengthening. In-service training targets have also been established by program area.

THIS IS A NEW BUDGET CODE NARRATIVE ACTIVITY

The goal of this new budget code is to decrease new HIV infections in the Ministry of Defence/Namibian Defence Force (MOD/NDF) through the establishment and expansion of male circumcision (MC) services. The military is considered a high risk group and is predominately male, typically young, and highly mobile. Therefore, building the capacity of and providing technical assistance to the MOD/NDF to offer MC services is critical.

This budget code is in line with the new PEPFAR guidance and is responding to the strategies and principles of the Partnership Framework Agreement (PFA) and the Namibian National Strategic Framework (NSF) to offer medical male circumcision (MC) services, emphasizing that MC be offered as part of an expanded approach to reduce HIV infections in conjunction with other prevention programs, including HIV testing and counseling (TC), treatment for other sexually transmitted infections (STIs), promotion of safer-sex practices and condom distribution.

This budget code has two main components: (1) assist the MOD/NDF to participate in the national MC pilot by building human capacity and procuring equipment and supplies, and (2) support the MOD/NDF to consolidate lessons learned from the pilot and scale-up MC services. In COP09, PEPFAR worked closely with the Ministry of Health and Social services (MoHSS) and other donors in a national task force to develop an MC draft Policy that recognizes MC as an effective HIV prevention method alongside the ABC strategy. In the same year, I-TECH worked very closely with the MoHSS and the MOD/NDF to train and circumcise 50 MOD/NDF volunteers in an MC pilot.

a) IN COP10, the US DOD, through I-TECH, will support the MOD/NDF by assisting the MOD/NDF to: i) determine the feasibility of a second pilot site, ii) procure equipment and supplies for the military pilot

site(s), iii) train a minimum of four additional nurses and counselors, iv) establish a system for supportive supervision and quality assurance, and v) incorporate MC education into all risk reduction counseling. b) Under the pilot, free and confidential MC services will be offered to MOD/NDF staff by military health care workers (HCWs) as part of a comprehensive HIV prevention program which also includes HIV testing and counseling with referrals, treatment for other STIs, counseling on risk-reduction and safer-sex practices, and condom distribution. Following the fundamentals of MC care for facility-based services, military MC services will include informed and voluntary decision making, medically safe clinical procedures and quality assurance. c) Support the MOD/NDF to consolidate lessons learned from the pilot and scale-up. d) MC services, specifically to assist the MOD/NDF to: i) develop a military strategy and operational plan for scaling up services, (including a multi-year plan for meeting potential pent-up demand and quality assurance measures), ii) evaluate MC services and demand creation activities, including the establishment of an health management information system (HMIS), and iii) prepare the health system for scale up (including equipment/supplies procurement and staff training for any new sites or mobile services outlined in the military scale-up strategy).

Support to MOD/NDF in quality assurance (QA) includes assisting the MOD/NDF to adopt or adapt MoHSS quality standards, presenting options to MOD/NDF for methods for monitoring quality and models to improve quality. I-TECH will assist MOD/NDF to tailor national pilot supportive supervision and QA tools to the military setting.

Activities contribute to the sustainability of military MC services through capacity building of military HCWs, procurement of equipment, and strengthening quality assurance systems. Support in training and quality assurance measures, as well as transitional funding to expedite scale up efforts are included as USG commitments in the Partnership Framework Agreement.

Personnel constraints limit targets for the number of males circumcised as part of the minimum package of MC for HIV prevention. It is estimated that six person days of physician time can be devoted to MC procedures each month for eight months. Assuming that five to six procedures could be completed each day, in COP10, the military could complete approximately 275 procedures among men above 15 years of age. Currently one military facility is committed to participate in the national MC pilot. A second facility will be assessed for suitability.

MC will be conducted on a voluntary basis on HIV-negative soldiers and services will be attentive to socio-cultural context, human rights and ethical principles, health services strengthening, training, gender implications, service delivery, and program evaluation.

THIS IS A CONTINUING BUDGET CODE NARRATIVE AND HAS BEEN MODIFIED AS FOLLOWS:

The goal of this continuing budget code narrative is to assist the military to provide effective and quality laboratory testing services to support military HIV service delivery. The US Department of Defence, through the International Training and Education Centre on HIV (I-TECH), will continue to support the Ministry of Defense/Namibian Defense Force's (MOD/NDF) laboratory program.

The narrative has been modified to reflect the new PEPFAR guidance and linkages to the Partnership Framework Agreement (PFA) and the Namibian National Strategic Framework (NSF).

The military's recently launched laboratory facility is the military's first facility that caters for HIV screening, CD4 and other basic laboratory bio-clinical monitoring tests necessary for the diagnosis of HIV infection, evaluation of patients before initiation of ART, and for the monitoring of patients on ART. This budget code activity will continue to strengthen the laboratory services in the MOD/NDF.

The activity has five components, namely to assist the MOD/NDF to: (1) Ensure appropriate use and maintenance of equipment, (2) finalize draft Standards Operation Procedures, (3) build human resource capacity of military laboratory staff through mentoring and in- service and pre-service training, (4) facilitate accreditation of the laboratory, and (5) establish and strengthen a laboratory network.

(1) I-TECH will assist the MOD/NDF to ensure appropriate use and maintenance of the equipment, establish an effective and sustainable equipment maintenance process in order to ensure uninterrupted services, including arranging for continuing maintenance contracts for the new CD4, hematology, and chemistry analyzers and additional laboratory equipment will be procured as necessary. (2) In COP10, I-TECH will assist the MOD/NDF to review and finalize draft laboratory Standard Operating Procedures (SOP). (3) To build the human resource capacity of military staff necessary to ensure provision of quality and sustainable laboratory support services, I-TECH will provide mentoring, and pre-service and in-service training. I-TECH will continue to provide routine mentoring for military laboratory technologists and laboratory assistants. In anticipation of expanding and sustaining laboratory services, I-TECH will collaborate with the MOD/NDF to facilitate the enrollment of military staff in the Polytechnic of Namibia's pre-service degree program for laboratory technologists. To further enhance skills, local and international in-service training will be provided through linkages with the Namibia Institute of Pathology (NIP) and

Centre for Disease Control (CDC's) International Laboratory Branch Consortium partners. (4) I-TECH will continue to assist the MOD/NDF to take steps toward achieving laboratory accreditation through the South African National Accreditation System, SANAS. A key step toward accreditation is assisting the military to ensure high quality laboratory services through strengthening internal quality assurance and continued enrollment in an External Quality Assurance (EQA) program that meets the requirements of the SANAS and the International Medical Laboratory Accreditation Community. (5) I-TECH will provide technical assistance to the MOD/NDF to establish and strengthen a laboratory network. The laboratory currently provides services to the adjacent military hospital and has the potential to provide testing to HIV service delivery sites at nearby military bases should the military decide to pursue this option. Quality assurance and technical support for the laboratory network will focus on pre- analytical (client preparation, specimen collection, storage, specimen referral system) and post-analytical (results reporting, archiving, specimen storage and disposal) processes.

As mentioned above, quality assurance support for the laboratory network will focus on pre-analytical and post-analytical, as well as external quality assurance.

In keeping with the MOD/NDF's focus on sustainability, the military has assumed responsibility for the majority of recurrent costs, such as personnel costs, facility maintenance, and procurement of supplies, test kits, and reagents. To further contribute to the sustainability of military laboratory services, I-TECH is assisting the military to establish and strengthen internal and external quality assurance systems, build the capacity of military laboratory staff through in-service and pre-service training, and enhance the close collaboration between the MOD/NDF and the Namibia Institute of Pathology (NIP).

Close collaboration with NIP is also a key component of the MOD/NDF's sustainability strategy for continued laboratory training, procurement of supplies, and other technical assistance. The NIP will provide continued in-service training and technical support to the MOD/NDF laboratory staff and management. Additionally, the NIP will act as a referral laboratory for tests and services not available at the MOD/NDF laboratory. Pre-service training to prepare additional military staff to become laboratory technologists is crucial to the sustainability of the MOD/NDF's program.

THIS IS A NEW BUDGET CODE NARRATIVE

The goal of this new budget code narrative is to decrease HIV/TB co-infections in the Ministry of

Defence/Namibian Defence Force (MOD/NDF). It is expanding on previous capacity building for the Namibian military in opportunistic infections, palliative care, and integrated management of adult illness (IMAI). This activity is a priority because military staff are at high risk for HIV and many military staff reside in congregate living settings that facilitate TB transmission.

The budget code has three main components that will assist the MOD/NDF to: (1) build capacity in service delivery, monitoring, and evaluation; (2) establish referral systems; and (3) strengthen infection prevention.

They key activities of this budget code narrative include:

1) Assisting the military to scale-up the current TB services for HIV-infected clients, I-TECH will provide technical assistance to the MOD/NDF to conduct a situational analysis of TB prophylaxis and TB/HIV treatment in the military. To build capacity in service delivery, I-TECH will continue to train military nurses and doctors to offer TB treatment and prophylaxis to HIV-infected clients. Nurses and medics will be trained in adherence counseling to promote completion of drug regimens. In addition, the MOD/NDF will be assisted to establish a recording and reporting system for Isoniazid Preventive Treatment (IPT). I- TECH will continue to support the MOD/NDF to reinforce linkages with the National TB Control Programme for the reporting of TB cases. 2) I-TECH will assist the military to build a strong referral network for cases with drug resistance beyond the military's capacity to treat, or sputum negative TB suspects at facilities not staffed by a physician. Military sick bays on each base can also assist MoHSS to promote adherence and trace defaulters. 3) To strengthen infection control, I-TECH will assist the MOD/NDF to conduct a situational analysis and to enhance prevention policies, policy implementation, and infrastructure in line with Namibian MOHSS TB infection control policies.

Supportive supervision and quality assurance (QA) activities will ensure linkages with the National TB Control Programme and strengthen MOD/NDF systems. Through linkages to the national programme, the MOD/NDF will participate in quarterly regional monitoring and evaluation reviews of TB services. In addition, I-TECH will assist the MOD/NDF to establish systems for internal and external quality assurance, including quarterly palliative care meetings and annual supportive supervision visits. To complement these systems, I-TECH clinical and/or nursing mentors will assist military staff through regularly scheduled on-site mentoring and support that includes support for TB prophylaxis services, screening for and treatment of TB disease in HIV-infected clients, and referral follow-up. Through this capacity building effort, I-TECH will also ensure that MOD/NDF take full ownership of managing the TB/HIV program.

The budget code contributes to sustainable MOD/NDF services through enhancing the capacity of military health systems and strengthening QA. From the outset, MOD/NDF assumed responsibility for the majority of recurrent costs, such as all personnel costs, the operation of military health facilities, anti-TB medicines and key supplies. COP10 activities will assist the MOD/NDF to further build capacity, strengthen infrastructure for infection prevention, and enhance QA. Additionally, linkages to the National TB Control Programme and local hospitals provide a continuous link to up-to-date TB information and guidelines, QA for TB cases, and referral points for TB cases that cannot be treated within military facilities.