FANTA-2 is a continuing implementing mechanism from FY09.

1. Goals and objectives: FANTA-2 works to improve nutrition and food security policies, strategies and programs through technical assistance (TA) to the USG and its partners including host countries, international organizations, and non-governmental (NGO) partners. The objectives of the program in Namibia are: 1) to provide TA to consolidate and scale up of integrated food and nutrition programs for eligible PLHIV and OVC; and 2) to improve nutrition and food security programs as well as livelihood support through TA to host country government entities and NGO partners.

Since COP07, FANTA-2 has designed PEPFAR-funded nutrition support for malnourished PLHIV and provided TA to strengthen the capacity of health care workers (HCW) in nutrition assessment, education, and counseling (NAEC) and support in HIV care and treatment sites. Activities link with USAID/Namibia's aims to strengthen the effectiveness of services and improve malnourished ART client outcomes through targeted, time-limited nutrition support; these activities also support UNICEF's work with the national integrated management of acute malnutrition program and the World Food Program's efforts to improve food security of PLHIV.

2. Link to Partnership Framework (PF) goals and benchmarks: FANTA-2 will continue to work with the Ministry of Health and Social Services (MOHSS) and PEPFAR implementing partners to improve client outcomes by strengthening NAEC, therapeutic and supplementary feeding of eligible adult and pediatric ART clients, PMTCT clients, and OVC. The food by prescription (FBP) approach initiated with FANTA-2 TA in COP09 and provision of TA to host government agencies and local NGOs to improve nutrition and food security policies and programs is in line with the National Strategic Framework (NSF), PF and Namibian National guidelines.

FANTA-2 TA aims to contribute to the following PF goals and objectives: • Pediatric and adult treatment care and support: FANTA-2 will improve ART adherence and treatment outcomes by supporting training and TA for the MOHSS to provide quality NAEC.

• Prevention: FANTA-2 will strengthen NAEC in PMTCT sites and improve clinic-community linkages. • Impact mitigation: FANTA-2 will enhance nutrition for vulnerable households by working with the MOHSS and possibly Ministry of Agriculture, Water and Forestry to integrate food and nutrition into HIV programs and services.

3. Coverage and target populations: FANTA-2 activities will cover the national level (capacity building of the MOHSS to guide and monitor nutrition support and food security interventions for eligible clients) and regional clinic- and community-based care services supported by PEPFAR. Target populations include clinically malnourished adult PLWHA, HIV-positive pregnant and lactating women regardless of nutritional status, and OVC, including pediatric ART clients.

4. Contributions to health systems strengthening: Training of HCW in NAEC.

5. Cross-cutting programs: FANTA-2's activities in COP10 will support two cross-cutting PEPFAR programs under Food and Nutrition: Policy, Tools, and Service Delivery; and Human Resources for Health.

FANTA-2 will support consolidation of services in pilot FBP sites with a possible expansion to other sites if Global Fund resources become available. FANTA-2 will continue to work with the MOHSS to promote NAEC as a standard of care in HIV and OVC services; support training and reprinting of job aids and counseling cards; and visit sites to assure the quality of NAEC and follow-up. FANTA-2 will assist the MOHSS in strengthening systems for follow-up, mentoring, and supervision of trained service providers and document lessons from the FBP sites and/or specific components to inform further programming. FANTA-2 will work with relevant entities to address food security and livelihoods.

6. Cost-efficiency strategy: FANTA-2 will contribute to the sustainability of nutrition interventions in HIV services by continuing to build the capacity of HCW in NAEC and provision of specialized food products to treat malnutrition. Trained trainers and instructors will be available to train others on an ongoing basis. National nutrition and HIV guidelines and counseling materials will be available for reproduction or reprinting by other partners as needed. Supporting expansion of nutrition and HIV services will make these services more cost-efficient because of economies of scale. Integrating nutrition interventions into existing care and treatment services will be cost efficient because new services are not needed and existing services will improve outcomes. Support for local production of specialized food products may lead to greater cost efficiency.

7. M&E plans: FANTA-2 will work with HIVQUAL, a quality improvement program, and the USG to adapt the HIVQUAL facility self-assessment tools, which focus on food security, to assess NAEC quality in FBP

sites. A full M&E plan will be developed along with plans to ensure data quality of program results. FANTA-2 will also support MOHSS staff to conduct regular site visits for supportive supervision, a crucial element in data quality assurance.

This is a continuing activity from FY 2009 with an expanded focus to improve food and nutrition security for PLHIV and vulnerable households. This activity has five main components: 1) scaling up the integration of nutrition assessment, education and counseling (NAEC) to additional ART sites; 2) establishing a mentoring and supervisory system for health care workers (HCW) who have been trained in nutrition and HIV at ART and PMTCT sites; 3) expanding linkages between clinic and community nutrition, food security, and livelihood interventions; 4) reviewing lessons from FBP implementation sites to improve understanding of the effectiveness of the approach in Namibia; and 5) supporting food security and livelihood interventions.

Since FY 08, FANTA has worked with the MOHSS Food and Nutrition Sub-Division to assess the food

and nutrition needs of PLHIV in Namibia; produce nutrition and HIV assessment and counseling job aids and IEC materials; develop two-day skills-based NAEC training module; and develop operational guidelines for food supplementation for PLHIV. FANTA-2 also supported the MOHSS in initiating the implementation of a FBP program integrated into HIV service provision. In FY09, FANTA-2 assisted the MOHSS and International Training and Education Center on HIV/AIDS (I-TECH) to enhance the NAEC and FBP content of the national training manual on nutrition and HIV, and train regional health managers and HCW in pilot FBP sites as well as community home-based care providers using this training material.

1. In COP10, FANTA-2 will support the MOHSS in scaling up the integration of NAEC into standard patient care to cover all 34 district ART sites, at least ten satellite ART clinics and 41 PMTCT sites. Provision of specialized food products for eligible clients will be scaled-up based on lessons from the pilot. Support will include assisting the MOHSS in updating and reprinting nutrition and HIV job aids and counseling materials.

2. FANTA-2 will continue to assist the MOHSS in building the capacity of clinic- and community-based HCW to provide NAEC and therapeutic and supplementary foods for malnourished ART, PMTCT and HBC clients. To support these efforts, FANTA-2 will support the MOHSS in training 12 regional health managers (two in each of six regions) and 100 ART site HCW in the national nutrition and HIV course (in regions not covered during the initial roll-out of the FBP program). The trained regional health managers will then train service providers at the FBP sites.

FANTA-2 will work with the MOHSS and I-TECH/Namibia to establish and implement an effective mentoring and supervisory system for HCW in ART and PMTCT sites who have been trained in nutrition and HIV. This support will help assure the quality of nutrition counseling and assessment and improve client coverage and follow-up as well as reporting.

3. The challenge in COP10 will be to consolidate and scale up these gains and ensure the quality and sustainability of NAEC, provision of specialized food products to treat acute malnutrition, and links to nutrition and livelihood support services for PLHIV who graduate from the FBP program.

4. As the FBP program expands in COP10, FANTA-2 will work with the MOHSS and partners to review initial results and lessons from implementation sites to improve understanding of its effectiveness. The review will cover processes, efficiencies, participant perceptions, acceptability of food products, challenges and initial outcomes. Findings of the review will be disseminated to stakeholders through a one-day workshop and used to inform further integration of nutrition into HIV services in Namibia.

5. Building on efforts in COP09 to support linkages between clinic and community nutrition services and

other food security and livelihood efforts in collaboration with Pact, FANTA-2 will provide TA to 20 additional health facilities to link PLHIV with opportunities to mitigate food insecurity. Such opportunities may include World Food Program (WFP) food assistance to improve food security of PLWHA families and caregivers. FANTA will support national strategies to increase food security and nutrition for vulnerable households and work in collaboration with Pact to build the capacity of NGOs, communities and PLHIV support groups' caregivers for improved practices for nutrition, food security and livelihoods.

The activities described above will contribute to the sustainability of FBP services in Namibia by strengthening the capacity of the MOHSS to coordinate and monitor FBP services, building and maintaining the capacity of nutrition and HIV trainers to train and supervise health care providers in ART sites, and strengthening quality assurance of FBP services.

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