SUBSTANTIALLY CHANGED FROM LAST YEAR The HHS/HRSA cooperative agreement with I-TECH Namibia is a continuing mechanism from FY09. CDC Namibia provides oversight for these activities. This

mechanism aims to build the capacity of the Ministry of Health and Social Services (MOHSS), and the University of Namibia (UNAM) to train healthcare workers to deliver HIV and other healthcare services. These activities also leverage and complement other PEPFAR investments in health systems strengthening.

Objectives: I-TECH Namibia has 10 objectives under this mechanism: (1) Increase health workers' capacity to provide integrated PMTCT services in MCH/ANC sites, including early infant diagnosis (EID); (2) Increase HCW ability to provide sexual prevention messaging, including information on sexually transmitted infections and prevention with positives; (3) Increase HCW ability to deliver male circumcision services; (4) Increase public and private sector HCW capacity to provide effective ART to adults as part of comprehensive HIV care and treatment services; (5) Increase public and private sector HCW capacity to provide effective care and treatment to children living with HIV/AIDS; (6) Increase public and private sector HCW capacity to diagnose and treat TB/HIV co-infection; (7) Increase MOHSS capacity to provide HCT services, including couples counseling and rapid HIV testing (RT); (8) Disseminate HIV training program results and lessons learned to government, partners, and other stakeholders as part of an integrated M&E strategy; (9) Increase HIV content in pre-service and in-service nurse training curricula; (10) Increase MOHSS capacity to utilize Digital Video Conferencing (DVC) facilities to strengthen and expand the National HIV/AIDS response.

Partnership Framework: This mechanism encompasses a broad range of activities and commitments described in the Partnership Framework currently under development. This mechanism supports key objectives under all four thematic areas, specifically: Prevention (male circumcision and PMTCT), Treatment, Care and Support (TB/HIV, palliative care and ART services), Impact mitigation (food security/nutrition), and Coordination and Management (human resources/human capacity development, and monitoring and evaluation).

Coverage: The activities under this mechanism are national in scope. The target populations include: doctors, registered nurses, enrolled nurses/midwives, pharmacist assistants, and laboratory staff. I-TECH works with the National Health Training Center (NHTC) network and UNAM to train in-service and pre- service healthcare workers. The NHTC network consists of the national center in Windhoek, and four regional training centers. In addition, I-TECH works with the Faculty of Medical Science at UNAM to train student nurses on HIV-related topics. For the past five years, this mechanism has supported a UNAM review of its nursing curricula to integrate HIV topics. In addition, through this mechanism, clinical instructors are recruited and deployed to UNAM and the NHTC network to teach HIV components of the revised curricula. HIV clinical mentors are recruited and deployed to high-volume sites to strengthen the capacity of local physicians to deliver quality HIV care and treatment. These mentors also support HCW to implement strategies to mainstream HIV services with other healthcare services.

Health systems strengthening: The key contributions of this mechanism relate to in-service and pre- service capacity development of HCW. This mechanism contributes to the global PEPFAR goal of training 140,000 new HCW. This mechanism supports long-term national capacity building by providing support exclusively to Namibian institutions (NHTC and UNAM).

Cross-cutting/Key issues: This mechanism will contribute to Human Resources for Health objectives through cross-cutting support for in-service and pre-service education for public health professionals. Cross-cutting technical assistance supported by this mechanism will emphasize nutrition policy development, other healthcare curriculum development and HCW training.

Cost efficiency: Activities supported under this mechanism are integrated with CDC's direct technical assistance to the MOHSS, both at the national level and in the field. By supporting training activities exclusively through MOHSS structures and systems, this mechanism avoids parallel or duplicative training efforts. Hiring of trainers, tutors and other key staff is coordinated with MOHSS and CDC through a cost-efficient local human resources contractor. I-TECH deliberately works with collaborating institutions to integrate recurrent costs, including staff salaries and benefits into the institutions' annual budgets. In COP09 alone, four regional trainers were fully absorbed into the NHTC (MOHSS) staff establishment.

M&E: The monitoring and evaluation of this mechanism includes PEPFAR indicators and a more detailed I-TECH M&E annual plan. I-TECH maintains a robust M&E system to capture progress towards objectives, to compare progress towards achieving goals, and to improve the quality of training and capacity building activities. A detailed M&E plan is developed each year and is reported to CDC and HRSA on a quarterly basis. Other data collection tools have been developed and are used to monitor outputs and outcomes of capacity building. I-TECH is committed to transferring operational control over these systems to its Namibian partners.

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This is a continuing activity from COP09, and includes four components: (1) Training to enhance health care workers (HCW) capacity to diagnose and manage STIs in PLWHA; (2) Strengthen STI surveillance among PLWHA; (3) Support training of doctors and pharmacists in clinical care of HIV/AIDS, and diagnosis and management of opportunistic infections (OIs), and; (4) training of nurses in HIV/AIDS related nutrition. 1. STI Capacity Building: HCW capacity to correctly diagnose and manage STIs using the syndromic management approach will be enhanced and monitored. Various tools including IEC materials, STI management flow charts, and wall charts will be developed to strengthen training in health facilities. In addition, the STI guidelines will be disseminated. I-TECH will conduct three trainings for HCW, with 25 participants each, for a total of 75 people trained. 2. Strengthen STI Surveillance: Monitoring of STI management is essential for evaluation of patient care and program performance. The I-TECH STI Technical Advisor, in collaboration with the MOHSS and a technical working group, will develop an STI surveillance tool. This will be piloted in four districts located in the four regions of Namibia with the highest STI burden. Three sites will be selected per district. Three participants per site will be trained in a one day course for a total of 36 HCW trained. 3. Support Training in Clinical HIV Care and OIs: I-TECH will enhance doctors' and pharmacists' capacity

to appropriately diagnose and manage OIs through trainings. I-TECH, in collaboration with MOHSS and a technical working group, will revise the curriculum for "Clinical Care of HIV, AIDS and Opportunistic Infections" to correspond to new national guidelines. The curriculum will also build skills for HCWs to assess and manage pain; provide appropriate psychological, social, and spiritual support with the goal of improving the quality of life for PLWHA. I-TECH will conduct two trainings with 20 government doctors and pharmacists each, as well as two trainings for 10 private doctors each, for a total of 60 people trained. 4. Training of Nurses in HIV/AIDS related Nutrition: Nutrition is a critical component of improved treatment outcomes for PLWHA. It is critical that nurses are provided with the skills and knowledge to enable them to address nutrition related issues in the health care setting. I-TECH will continue to support the revision of the curriculum on HIV/Nutrition Management and will conduct three regional trainings, of 25 participants each, for a total of 75 HCW trained. One Trainer of Trainers for HIV/Nutrition will also be conducted. Supportive Supervision/Quality Assurance/Quality Improvement: I-TECH HIV clinical mentors will provide mentoring support to clinicians following training in clinical management of HIV/AIDS and OIs. The CM will use data from other monitoring tools used by the MOHSS and HIVQUAL to drive the improvement of the quality of care. The I-TECH STI Technical Advisor in collaboration with other MOHSS staff will undertake two weeks of supportive supervisory visits to health facilities to assess quality of implementation of STI management. Quality Assurance for STI surveillance will be enhanced through the piloting of a new STI surveillance tool. In addition, the STI technical advisor, in collaboration with MOHSS, will conduct supportive supervisory visits to selected sites to assess their implementation of the syndromic management of STIs. Tutors in the regions will use a structured support visit tool to assess nutrition service provision and will provide on-site mentorship and support as needed. Sustainability: I-TECH's focus on technical assistance rather than service delivery promotes national ownership and reduces MOHSS dependency on external experts. I-TECH does this through support for in-service training as well as pre-service training to nursing students at the National Health Training Centre (NHTC) and University of Namibia (UNAM). Additionally, I-TECH provides training to doctors, pharmacists and nurses in both the public and private sectors, to support compliance to standardized treatment guidelines in HIV, STI, and TB care and treatment. The training of Namibian trainers is a prime example of I-TECH's commitment to local ownership. Training on the Syndromic Management of STI will be sustained by Namibian staff who have received training as trainers. Country ownership will be further enhanced as more of these local trainers are absorbed by the MOHSS as civil service staff of the National Health Training Center. The development of "Guidelines for the Clinical Management of HIV and AIDS" and the revision of the "Clinical Care of HIV, AIDS and Opportunistic Infections" curricula will promote standardization of skills across the public and private healthcare sectors, and support the GRN's push to decentralize healthcare training and decision-making. As noted in other BCN, I-TECH is

committed to strengthening and integrating GRN data systems. These systems play an increasingly important role in GRN decision-making and have allowed the development of evidence-based strategies, including the new National Strategic Framework (NSF).

NEW/REPLACEMENT WITH SUBSTANTIAL CHANGES

This is a continuing activity from COP09, and includes six components: (1) Training in management of antiretroviral therapy (ART); (2) HIV Clinical mentors; (3) training for cervical cancer screening; (4) training of health care workers (HCW) and expert patient trainers in the Integrated Management of Adult Illnesses (IMAI) strategy; (5) training for Clinical Instructors, and; (6) training of nurses in adherence counseling. 1. ART training: Capacity to manage ART in adults with HIV will be enhanced through training. The current curriculum will be updated based on recent ART guidelines. I-TECH will conduct two basic ART courses for public sector doctors and pharmacists, with 20 participants each, for a total 40 people trained. An advanced curriculum on ART in adults and TB management will be revised and used to conduct two courses, with 20 participants each, for a total of 40 trained. In addition, one course in advanced ART and TB for ten private practitioners will be held. 2. HIV Clinical Mentoring for Doctors: Six HIV expert physician clinical mentors will continue to provide mentoring support primarily to doctors in 10 of the 13 regions. Clinical mentors will also assess training needs and routinely provide didactic and hands-on training. They will assist clinics to establish systems such as efficient patient flow to reduce patient waiting times. They will also promote a multi-disciplinary approach to HIV care, and strengthen mechanisms to address site specific patient retention and referrals including the use of outreach and bi-directional referral systems. Guidelines, medical textbooks, and journals will be procured and placed in resource centers. 3. Cervical Cancer Screening capacity building: HCW capacity to perform cervical cancer screening will be enhanced through training. In collaboration with MOHSS, I-TECH developed a concise, practical, on- site training curriculum for conducting pap smears in women with HIV infection. I-TECH will support eight training courses, with ~8 eight HCW per site, for a total of 64 HCW trained. Equipment required for the on-site training will also be procured. I-TECH will develop a register which will allow facilities to record screened patients and track test results to ensure that patients receive their results and required services. 4. Training of HCW and Expert Patient Trainers in IMAI: I-TECH will continue to support task shifting through IMAI training. I-TECH will update the IMAI curriculum to reflect national task shifting protocols.

Three regional IMAI trainings for nurses and community counselors will be conducted, with 60 participants each, for a total of 180 participants trained.

5. Training in Clinical Mentoring for Nurses: I-TECH will continue supporting clinical mentoring of nurses by recruiting an additional nurse mentor and training 34 newly recruited regional Clinical Instructors who will be placed in the districts. These instructors will provide nurse mentoring support in the regions. In addition, the nurse clinical mentors will work closely with IMAI facilities and will provide technical assistance and support to nurses at these facilities.

6. Training of Nurses in Medicine Adherence Counseling: I-TECH will continue training nurses in adherence counseling, printing of training materials and procurement of supplies and equipment for training. With COP10 funds, I-TECH will conduct one TOT training for 20 people, and 3 regional trainings, of 27 participants each, training a total of 81 HCWs.

7. Supportive Supervision/Quality Assurance/Quality Improvement: Clinical mentors will provide supportive supervision at health facilities providing ART, including the performance of pap smears for HIV positive women. Clinical mentors will also assess quality of care provided by mentees every six months from using tools from MOHSS and HIVQUAL to improve the quality of care. Sustainability: I-TECH's focus on technical assistance rather than service delivery promotes national ownership and reduces MOHSS dependency on external experts. I-TECH does this through support for in-service training as well as pre-service training to nursing students at the National Health Training Centre (NHTC) and University of Namibia (UNAM). Additionally, I-TECH provides training to HCWs in both the public and private sectors to support compliance to standardized treatment guidelines in HIV, STI, and TB care and treatment. The training of Namibian trainers is a prime example of I-TECH's commitment to local ownership. Training on IMAI and treatment adherence will be sustained by Namibian trainers and mentors who have received training as trainers. I-TECH support for training of lay health care workers will also promote the GRN's task-shifting initiative and reduce workloads on doctors and nurses. Country ownership will be further enhanced as more of these local trainers are absorbed by the MOHSS as civil service staff of NHTC. The development of guidelines and revision of curricula will promote standardization of skills across the public and private healthcare sectors, and support the GRN's push to decentralize healthcare training and decision-making. As noted in other BCNs, I-TECH is committed to strengthening and integrating GRN data systems. These systems play an increasingly important role in GRN decision-making and have allowed the development of evidence-based strategies, including the new National Strategic Framework (NSF).

NEW/REPLACEMENT NARRATIVE WITH SUBSTANTIAL CHANGES

This is a continuing activity from COP09. It includes three components: (1) Training of nurses and

community counselors in HIV counseling; (2) training of HCW in rapid HIV testing, and; (3) development

of training videos.

1. Training in HIV Counseling and Testing: HCT is the entry point for PLWHA to access care and

treatment. Accordingly, there is a great need to train nurses and community counselors (CC) throughout

the country to increase service coverage. Nurses and CC will be trained in HCT. The counseling

component involves training in HIV individual counseling, couples HIV counseling and testing (CHCT)

and Provider-initiated testing and counseling (PITC). In COP10, a total of 108 health workers will be

trained in both VCT and PITC. This is in line with the MoHSS's goal of increasing the number of persons

receiving CT, and to identify those in need of care and treatment. Three additional trainings in CHCT will

be conducted to train a total of 81 health workers. Overall, a total of 189 HCW will be trained in HCT.

2. Rapid Test Training: Rapid testing is critical in identifying patients with HIV and getting them into care

and treatment. Rapid testing allows clients to receive their HIV test results on the same day. This

approach has vastly increased the uptake of HIV testing, and increased the percentage of people who

know their HIV results. To promote universal access to rapid testing, training of nurses and CC

throughout Namibia is essential. In COP10, one training of trainers (TOT) will be held for 20 participants.

These trainers will conduct an additional three trainings for 80 HCW. Two groups of CCs with a total of 52

participants will also be trained. Overall, a total of 132 HCW and CCs will be trained in rapid testing with

COP10 funding.

3. Development of Training Videos: Interactive training materials, such as videos, are known to be highly

effective in transferring knowledge to trainees. In COP10, I-TECH will complement existing HCT print

materials by developing videos. One short rapid testing video will be produced which will clearly

demonstrate how to correctly perform the parallel rapid HIV testing algorithm. Because of the

demonstrated prevention effectiveness of CHCT, a second short video will be produced on counseling

discordant couples. This will be used during the CHCT trainings.

Supportive Supervision/Quality Assurance: Using structured clinical support visit assessment tools, tutors

from the Regional Health Training Centres will conduct quarterly clinical support visits to facilities

providing HCT services. These visits will promoted the transfer of learning and provide on-site

mentorship. During these visits, two to three tutors will work as a team and will assess the facility,

supplies, and HCT service provision. Depending on the size of the facility, these visits, which will be

coordinated with the MOHSS, may take from one to five days.

Sustainability: I-TECH's focus on technical assistance rather than service delivery promotes national

ownership and reduces MOHSS dependency on external experts. I-TECH does this through support for

in-service training as well as pre-service training to nursing students at the National Health Training

Centre (NHTC) and University of Namibia (UNAM). Additionally, I-TECH training to doctors, pharmacists

and nurses in traditional healthcare settings as well as in the correctional system will promote the use of

standardized counseling, testing and treatment guidelines for HIV, STI, and TB. Funding through the

HVCT technical area will further enhance professional and lay healthcare workers' ability to delivery HCT

at the facility and community level. The training of Namibian trainers is a prime example of I-TECH's

commitment to local ownership. Sustainability of the HVCT training program will be promoted through

multiple means. Training on HCT will be sustained by Namibian trainers and mentors who have received

training as trainers. I-TECH support for training of lay health care workers will also promote the GRN's

task-shifting initiative and reduce workloads on doctors and nurses. Country ownership will be further

enhanced as more of these local trainers are absorbed by the MOHSS as civil service staff of the

National Health Training Center. The development of national training curricula for HCT will promote

standardization of skills across the public and private healthcare sectors, and support the GRN's push to

decentralize healthcare training and decision-making. As noted in other BCN, I-TECH is committed to

strengthening and integrating GRN data systems. These systems play an increasingly important role in

GRN decision-making and have allowed the development of evidence-based strategies, including the

new National Strategic Framework (NSF).

NEW/REPLACEMENT NARRATIVE WITH SUBSTANTIAL CHANGES

This is a continuing activity from COP09 which includes 3 components: (1) training of doctors, pharmacists and nurses in comprehensive pediatric HIV care; (2) training and supervision by HIV Clinical Mentors (CM) to support healthcare workers (HCW) managing children with HIV and; (3) training on Community Based Child Growth Monitoring (CBCGM). 1. Pediatric HIV care training for doctors, nurses and pharmacists. Doctors, nurses and pharmacists' capacity to manage children with HIV will be enhanced through training in comprehensive pediatric HIV care using a curriculum which includes clinical pre-ART and ART care, management of common clinical conditions and opportunistic infections (OI), nutrition, growth monitoring, psychosocial challenges, and other palliative care. The current curriculum will be updated to align with the Namibian guidelines on the use of ART therapy in children (to be revised in COP10). An advanced ART curriculum addressing the use of ARV in adults and children, as well as the management of TB/HIV co-infection will be regularly revised and used to conduct training for public and private doctors and pharmacists already trained in the basic courses. I-TECH will continue to support revision of guidelines/policies related to nutrition, growth monitoring, infant and young child feeding; in line with international guidelines and evidence from the literature.

I-TECH will conduct 2 pediatric HIV/AIDS courses for government doctors, nurses and pharmacists, each with 20 people and 1 pediatric HIV/AIDS course for 10 private practitioners. An important module on HIV disclosure and psychosocial support especially for older children and adolescents will be delivered in an interactive manner for 10 and a TOT on this topic will be held for 12 participants for a total of 72 people trained. 2. HIV Clinical Mentoring: I-TECH will continue to support 6 experienced HIV physician CM who provide mentoring support primarily for doctors managing adults and children with HIV in 10 of 13 Namibia Regions (see Adult Treatment). CM will continue to assist facilities to focus on increasing access to early infant diagnosis, ART treatment of all confirmed HIV-positive infants <12 months, close monitoring of children =12 months to allow treatment at the earliest qualifying time and overall management of children with HIV, both before and after starting ART. Pediatric reference materials have been supplied to 16 ART sites, allowing easy access to information needed by HCW and will supply materials to 4 additional sites in COP10. 3. Support of Community Based Child Growth Monitoring and Promotion: I-TECH will support the initiation of CBCGM, which will aid in early identification of children with growth challenges resulting from HIV infection or related illness. This will coincide with support and promotion of exclusive breastfeeding with appropriate complimentary feeding for up to 2 years and beyond. I-TECH will also procure nutrition training materials and equipment and will print and disseminate infant and child nutrition related information, education and communication. Additionally, with COP10 funds, I-TECH will purchase infant/child nutrition related books for 8 resource centers within the National Health Training Network (NHTC) and the University of Namibia (UNAM). Two courses on Management of Severe Acute Malnutrition will be held with 25 participants each, for a total of 50 trained. Supportive Supervision/Quality Assurance/Quality Improvement: I-TECH HIV CM will provide mentoring support to clinicians following training in clinical management of HIV, AIDS and OI. The CM will work with HCW and use data from other PEPFAR supported quality monitoring tools such as HIVQUAL to drive the improvement of the quality of care provided by health facilities. Sustainability: I-TECH's focus on technical assistance rather than service delivery promotes national ownership and reduces MOHSS dependency on external experts. I-TECH does this through support for in-service training as well as pre-service training to nursing students at NHTC and UNAM. I-TECH also provides training to private and public doctors, pharmacists and nurses, to support compliance with HIV, STI, and TB care and treatment standardized guidelines. Funding through the PDCS technical area will further enhance clinicians' ability to diagnose and treat pediatric HIV patients. The training of Namibian trainers is a prime example of I-TECH's commitment to local ownership. Sustainability of the HBHC training program will be promoted through multiple means. Training on IMAI and treatment adherence will be sustained by Namibian trainers and mentors who have received training as trainers. I-TECH support for training of lay HCW will also promote the GRN task-shifting initiative and reduce doctors and nurses workloads. Ownership will be further enhanced as more local trainers are absorbed by the MOHSS as

NHTC civil service staff. The development of guidelines and revision of curricula will promote standardization of skills across the public and private healthcare sectors, and support the GRN push to decentralize healthcare training and decision-making. As noted in another BCN, I-TECH is committed to strengthening and integrating GRN data systems which play an increasingly important role in GRN decision-making and have allowed the development of evidence-based strategies, including the new National Strategic Framework.

SUBSTANTIAL CHANGES

This is a continuing activity from COP09, and includes three components: (1) Training of HCWs in comprehensive pediatric HIV care; (2) HIV Clinical Mentor support to HCWs managing children with HIV, and; (3) support for training in Community Based Child Growth Monitoring (CBGM). 1. Pediatric HIV care training: I-TECH will train HCWs in comprehensive pediatric HIV care using a curriculum which includes: clinical pre-ART and ART care; management of common clinical conditions and opportunistic infections; nutrition and growth monitoring; psychosocial challenges, and other palliative care issues. The current curriculum will be updated to include the WHO 2008 treatment recommendations to treat all HIV-infected infants less than 12 months with ART, without waiting for clinical and immunological criteria. I-TECH will assist in the revision of guidelines on the use of ART in children, which are expected to be revised in 2010. An advanced curriculum addressing the use of ARVs in adults and children as well as the management of TB/HIV co-infection will be used to conduct training for government HCWs who have already been trained in the basic courses. I-TECH will continue to support revision of guidelines and policies related to nutrition, growth monitoring, and infant and young child feeding to reflect international guidelines. I-TECH will conduct two training courses on pediatric HIV/AIDS, each with 20 people, for government doctors and pharmacists, for a total of 40 people. One pediatric HIV/AIDS training course for ten private practitioners will be conducted. In addition, a special course on HIV disclosure in children will be conducted with ten participants. Additionally, a TOT on this topic will be held for 12 participants, for a total of 72 individuals trained. 2. HIV Clinical Mentoring: I-TECH will continue to support six HIV physician Clinical Mentors who provide mentoring primarily for doctors managing adults and children with HIV in 10 of the 13 Regions in Namibia. Clinical Mentors will continue to assist facilities to focus on increasing access to early infant diagnosis and ART treatment of all infants < 12 months old who are confirmed HIV-positive. In addition, close monitoring of children =12 months to allow treatment at the earliest qualifying time, as well as

overall management of children with HIV, both before and after starting ART will be emphasized. As part of the clinical mentoring program, pediatric reference materials will be supplied to sites. 3. Support of Community Based Child Growth Monitoring and Promotion: In view of the shortage of HCWs, I-TECH will support the initiation of Community Based Growth Monitoring and Promotion (CBGMP), which will assist in early identification of children with poor growth as a result of HIV infection and related illness. This will coincide with support and promotion of exclusive breastfeeding with appropriate complimentary feeding for up to two years and beyond. In addition, I-TECH will procure nutrition training materials and equipment and will print and disseminate infant and young child nutrition related IEC materials. Furthermore, I-TECH will purchase Infant/child nutrition related books for eight resource centers within the National Health Training Network and the University of Namibia. Two courses on Management of Severe Acute Malnutrition will be conducted with 25 participants each, for a total of 50 people trained. Supportive Supervision/Quality Assurance/Quality Improvement: I-TECH HIV clinical mentors will provide mentoring support to clinicians following training in pediatric clinical management of HIV/AIDS. The CM will work with the HCWs and use data from monitoring tools used by the MOHSS and HIVQUAL to drive the improvement of the quality of care. Sustainability: I-TECH's focus on technical assistance rather than service delivery promotes national ownership and reduces MOHSS dependency on external experts. I-TECH does this through support for in-service training as well as pre-service training to nursing students at the National Health Training Centre (NHTC) and University of Namibia (UNAM). Additionally, I-TECH provides training to doctors, pharmacists and nurses in both the public and private sectors, to support compliance to standardized treatment guidelines in HIV, STI, and TB care and treatment. Funding through the PDCS technical area will further enhance clinicians' ability to diagnose and treat pediatric HIV patients. The training of Namibian trainers is a prime example of I-TECH's commitment to local ownership. Sustainability of the HBHC training program will be promoted through multiple means. I-TECH support for training of lay health care workers will also promote the GRN's task-shifting initiative and reduce workloads on doctors and nurses. Country ownership will be further enhanced as more of these local trainers are absorbed by the MOHSS as civil service staff of the National Health Training Center. The development of guidelines and revision of curricula will promote standardization of skills across the public and private healthcare sectors, and support the GRN's push to decentralize healthcare training and decision-making. As noted in other BCNs, I-TECH is committed to strengthening and integrating GRN data systems. These systems play an increasingly important role in GRN decision-making and have allowed the development of evidence-based strategies, including the new National Strategic Framework (NSF).

NEW/REPLACEMENT WITH SUBSTANTIAL CHANGES

This is a continuing activity from COP 09 which includes 4 components: (1) Training workshops in various health sector tools; (2) System for Program Monitoring (SPM) trainings; (3) support task-shifting demonstration project, and; (4) support for a training needs assessment (TNA).

1. Training workshops in various health sector tools. Health sector data collection, analysis, and use is the responsibility of the Ministry of Health and Social Services (MOHSS), Response Monitoring and Evaluation (RM&E) unit. The RM&E will train its regional staff, including data clerks and HIS officers, so they are proficient in collecting, entering, cleaning, and analyzing data. The training will build skills in data entry, management, and reporting to increase proficiency in using the MOHSS ART, PMTCT, HCT, TB and STI management information systems. Five training workshops will be held with 15 persons per training for a total of 75 trained.

2. System for Program Monitoring (SPM) trainings. The SPM is the system by which all non-health sector HIV/AIDS related activities are reported through the Ministry of Regional and Local Government to the National AIDS Commission. This activity will support 4 SPM refresher trainings for regional implementers, one report writing training for regional M&E officers and community liaison officers (CLO), and one M&E officers and CLO retreat. One workshop will be conducted to review and revise existing SPM data collection and reporting forms. A total of 5 trainings/workshops, with 20 people each will be conducted with a total of 100 trained. New SPM guidelines are being developed which will result in new trainings with a modified curriculum. Training of trainers will be used to implement the new guidelines.

3. Support Task-shifting Demonstration Project An evaluation of the feasibility, acceptability, and effectiveness of shifting uncomplicated case ART service provision from physicians to nurses will be demonstrated in 3 sites compared to continued physician ART service provision in 3 comparison sites. After 6 months, qualitative and quantitative methods will be used to compare the quality of care and health outcomes for ART patients in demonstration and comparison sites. The demonstration project will assess the feasibility and effectiveness of task-shifting to meet the increasing demands for HIV care and treatment given the on- going human resource (HR) shortages, especially in rural areas.

4. Support Training Needs Assessment (TNA). A TNA will assess the coverage and quality of HIV/AIDS training for Namibia health care workers (HCW). The TNA will use existing training data to graphically represent HIV/AIDS training coverage with HR data as well as population data by region. A quality assessment (QA) administered though HCW will assess

the transfer of skills from trainings to facilities which will identify training gaps/needs which will be used to tailor future trainings, better plan audiences for trainings, and enhance/modify existing HIV/AIDS curricula.

Supportive supervision/Quality Assurance: Supportive supervision of regional M&E officers is conducted through quarterly visits from the MOHSS RM&E. Data clerks also receive supportive supervision from quarterly visits from regional level staff in addition to annual supervision visits from national level staff. Gaps and areas for improvement identified through these regional and national visits are communicated to staff through reports disseminated after the visits. Teachers observe and follow up with participants after the courses to assess skills transfer.

Sustainability: I-TECH's focus on technical assistance rather than service delivery promotes national ownership and reduces MOHSS dependency on external experts. I-TECH does this through support for in-service training as well as pre-service training to data managers and other support staff at the National Health Training Centre (NHTC), the University of Namibia (UNAM), and within the MOHSS RM&E unit. Additionally, I-TECH training promotes the use of standardized data collection and management tools and indicators. Funding through the HVSI technical area will further enhance the GRN's ability to collect, manage, analyze and use data for evidence-based decision making. Training of Namibian trainers is a prime example of I-TECH's commitment to local ownership. Sustainability of the HVSI training program will be promoted through multiple means. Training on data systems, tools, and QA will be sustained by Namibian trainers and mentors who have received training as trainers. I-TECH support for training of lay HCW will also promote the GRN's task-shifting initiative and reduce workloads on clinicians and senior data managers. Country ownership will be further enhanced as more local trainers are absorbed by the MOHSS as civil service staff of the NHTC. The use of a national training curriculum for M&E will promote standardization of skills across the public healthcare system and allow for greater integration with data systems used by the private healthcare sectors. Integration and coordination will support the GRN's push to decentralize healthcare training and decision-making. As noted in other BCN, I-TECH is committed to strengthening and integrating GRN data systems which play an increasingly important role in GRN decision-making and have allowed the development of evidence-based strategies, including the new National Strategic Framework.

NEW/REPLACEMENT NARRATIVE WITH SUBSTANTIAL CHANGES This is a continuing activity from COP09. It includes three components: (1) Strengthen the National

Health Training Center's capacity to deliver in-service and pre-service training; (2) Strengthen University of Namibia's capacity to deliver quality pre-service training for Registered Nurses, and; (3) Assist MOHSS to utilize the Digital Video Conference system. 1. Strengthen National Health Training Center: With funds from COP10, I-TECH will continue supporting NHTC to revise nursing curricula, renovate class rooms and procure training equipment and materials. In addition, I-TECH will continue supporting NHTC to develop training standards, guidelines and a monitoring and evaluation system. Through COP10 funds I-TECH will continue training NHTC tutors who will implement facility-based follow-up and mentoring for former trainees. COP10 funds will also support the procurement of books and electronic materials for the NHTC resource centers. 2. Strengthen UNAM Capacity to deliver quality pre-service training: With COP10 funds, I-TECH will continue working with the Faculty of Medical Science to review nursing curricula and integrate the latest evidence-based information on HIV, TB and other health issues. Previously developed materials by I- TECH will also be reviewed and evaluated including the Lecturer's Resource Guide, which was developed and disseminated with COP08 funds. In addition, faculty development and training will continue with COP10 funds. Training material and equipment will also be procured through COP10 funds. 3. Assist MOHSS to utilize efficiently Digital Video Conference system: I-TECH will continue working with MOHSS and sub-national partners to strengthening the utilization of DVC. With COP10 funds, I-TECH will assist MOHSS to develop a five year plan to take over this activity by 2012. I-TECH will support this plan through training for MOHSS staff to operate and maintain the equipment and it programs. Supportive Supervision/Quality Assurance: Using structured DVC support visit assessment tools, DVC manager from I-TECH's Windhoek office will conduct quarterly DVC support visits to provide training and mentoring for local DVC operators. I-TECH developed monitoring and evaluation tools to assess all services and support provided to NHTC and UNAM. With COP10 funds, I-TECH will conduct assessments to evaluate the impact of DVC trainings and other training materials on skills uptake. Sustainability: I-TECH's focus on technical assistance rather than service delivery promotes national ownership and reduces MOHSS dependency on external experts. I-TECH does this through support for in-service training as well as pre-service training to clinicians, lay healthcare workers, data managers and other support staff at the National Health Training Centre (NHTC), the University of Namibia (UNAM), and within the MOHSS Response M&E unit. Additionally, I-TECH training promotes the use of standardized clinical guidelines and data collection and management tools and indicators. Funding through the OHSS technical area will further enhance the GRN's ability to collect, manage, analyze and use data for evidence-based decision making. Training of Namibian trainers is a prime example of I- TECH's commitment to local ownership. Sustainability of the OHSS training program will be promoted through multiple means. Training on data systems, tools, and quality assurance will be sustained by Namibian trainers and mentors who have received training as trainers. I-TECH support for training of lay health care workers will also promote the GRN's task-shifting initiative and reduce workloads on clinicians

and senior data managers. Country ownership will be further enhanced as more of these local trainers are absorbed by the MOHSS as civil service staff of the National Health Training Center. The use of national training curricula for M&E and clinical practice will promote standardization of skills across the public and private healthcare systems, and allow for greater integration of public and private data systems. Integration and coordination will support the GRN's push to decentralize healthcare training and decision-making. As noted in other BCN, I-TECH is committed to strengthening and integrating GRN data systems. These systems play an increasingly important role in GRN decision-making and have allowed the development of evidence-based strategies, including the new National Strategic Framework (NSF).

NEW/REPLACEMENT NARRATIVE WITH SUBSTANTIAL CHANGES This is a continuing activity from COP 2009. It includes four components: (1) Training of regional managers on the Namibian MC policy and its implementation; (2) training of trainers (TOT) in MC; (3) creation of an MC operational manual to be used in MC trainings, and; (4) training of doctors, nurses, and community counselors as MC service providers, including follow-up support visits to trainees for supportive supervision. 1. Orientation for Managers: In this activity, regional managers will be trained on the Namibian policy for Male Circumcision and its implementation. I-TECH, in collaboration with the MOHSS, will develop a curriculum for managers and provide two trainings, with 25 regional managers each, for a total of 50 people trained. 2. Training of Trainers: Roll-out of MC requires provision of services by clinicians highly trained on the theory and practice of the procedure. Skilled trainers of providers will therefore be needed. I-TECH will train ten clinicians who have demonstrated competence in performing MC in a TOT course. The trainees will then act as facilitators in future MC training courses. 3. Training of Service Providers: Training of doctors, nurses, and community counselors will be conducted as part of a national HIV prevention strategy. The MC training curriculum covers technical skills for clinicians. The curriculum for both clinicians and counselors focuses on MC as part of a comprehensive package which includes prevention counseling, provider initiated counseling and testing, active exclusion of STI and their syndromic management where required, and the promotion of consistent and correct use of condoms. It is anticipated that each course will cater to clinicians from four sites. Non-consumable surgical equipment and consumable commodities will be required for use in the training courses. Three trainings will be conducted for doctors, nurses and community counselors, with 25 participants each, for a total of 75 people trained. Supportive Supervision/Quality Assurance: Following the trainings for MC providers, a team from I-TECH

including a physician trainer and a nurse training manager will conduct supportive supervision visits to the 75 clinicians who received MC training (see above). One to two days will be spent at each site as required. A Quality Assurance assessment tool will be used to evaluate MC service provision and to assist in additional skills transfer where necessary. An experienced and technically competent MC physician trainer who can devote much of his time to the training is crucial. Therefore a physician trainer will be recruited to serve this purpose. Sustainability: I-TECH's focus on technical assistance rather than service delivery promotes national ownership and reduces MOHSS dependency on external experts. I-TECH does this through support for in-service training as well as pre-service training to nursing students at the National Health Training Centre (NHTC) and University of Namibia (UNAM). Additionally, I-TECH provides training to doctors, pharmacists and nurses in both the public and private sectors, to support compliance to standardized treatment guidelines in HIV, STI, and TB care and treatment. By building capacity of local teams in the districts to offer high quality male circumcision services, sustainability of the services will be enhanced. The training of Namibian trainers is a prime example of I-TECH's commitment to local ownership. Sustainability of the MC program will be promoted through multiple means. The development of MC curricula for managers, clinicians, and counselors will ensure standardization and strengthen the GRN's push to decentralize healthcare training and decision-making. As noted in other BCN, I-TECH is committed to strengthening and integrating GRN data systems. These systems play an increasingly important role in GRN decision-making and have allowed the development of evidence-based strategies, including the new National Strategic Framework (NSF).

SUBSTANTIAL CHANGES This is a continuing activity from COP09 includes 5 components: (1) training of healthcare workers (HCW) in prevention for persons living with HIV (PLWHA); 2) training alcohol-related HIV prevention; (3) HIV prevention training for case managers and expert patients; 4) quality assurance of the case management program, and; 5) training for HCW based in correctional facilities. 1) Training of HCW in Prevention for PLWHA. I-TECH will support the roll out of the training of Prevention for PLWHA curriculum. The core framework of this course is based on CDC's Prevention with PLWHA evaluation intervention and includes: prevention messaging (e.g., disclosure, partner testing, condom use, alcohol prevention), syndromic screening for STIs as well as the provision of FP counseling. The prevention course will also include a brief overview of TB and nutrition screening. I-TECH will continue to develop, revise, and print training materials, posters, patient-provider flipbooks, provider cards, and patient educational materials associated with the project. Five trainings will be conducted, with ~27

participants each, for a total of 135 health workers trained. 2) Alcohol Training. I-TECH will conduct training on the alcohol brief motivational interview (BMI) intervention as part of the above mentioned Prevention for PLWHA course. In addition, the course will be delivered to HCW outside of the ARV clinic settings, as well to correctional staff. I-TECH will develop a 2-day, stand alone alcohol BMI training course with training materials. I-TECH will conduct four trainings with 24 participants in each training, with at least two of those courses in the correctional setting. 3.Training for Case Managers (CM) and Expert Patients. In COP10, I-TECH will train 34 case managers (CM) that will be based within ART clinics and ANC sites. A client assessment tool will allow for early recognition of client issues that could impact compliance with care, treatment, prevention, and overall positive living. CM will coordinate clinical resources (e.g., FP, STI services, etc) as well as links to the community resources and social support. They will also assist with default tracing. As part of the development of the overall CM program, an assessment will determine the potential role and responsibilities of expert patients (e.g., default tracing, education, etc). I-TECH will provide training and support to the expert patients as part of the development of a comprehensive CM program. I-TECH will provide a minimum of 2 courses for expert patients (20 participants each). CM and expert patients will facilitate PLWHA support groups at facility level, as well as referrals to community PLWHA support groups. They will also provide referrals to other health and social services (e.g., counseling for drug/alcohol treatment and domestic violence). Particular emphasis will be placed on encouraging men to seek services and to support their partners and children in doing the same. 4. Quality Assurance of the Case Management Program. Using structured clinical support visit assessment tools, tutors from the National Health Training Centers/Regional Health Trainings Centers will provide quarterly visits to the facilities in their regions to ensure transfer of learning, provide on-site mentorship and support, identify gaps, and make recommendations for improvement. 5. Correctional Staff Training. In 2009, CDC supported an extensive review of HIV and TB activities within Namibia's correctional system. The review identified several areas for future support, including: TB and HIV training to clinical and correctional staff to increase awareness of TB/HIV co-infection and build skills to provide inmates with counseling and testing services for both diseases. Additional training was recommended to support an expansion of HIV/TB treatment services in prisons. In COP10, I-TECH will train ~80 correctional staff. Sustainability. I-TECH support for in-service and pre-service training to nursing students at the National Health Training Centre (NHTC) and University of Namibia (UNAM) contributes to the GRN's long-term strategy to develop integrated HCW training programs. This focus on integration across the healthcare system is a primary objective in the GRN's Human Resources for Health (HRH) strategy. Support for these national training institutions highlights I-TECH's focus on technical assistance rather than service delivery. I-TECH training for HCW further contributes to the national HRH strategy and supports standardization and coordination in HIV, STI, and TB care and treatment. Support for the CM program also builds the capacity of MOHSS by improving the ability of lay healthcare workers and expert patients

to absorb task-shifting responsibilities. These cadres will increasingly be absorbed into the MOHSS HR system, either as civil servants (e.g., through the Health Extension cadre) or as MOHSS-managed and financed contractors. Supportive supervision will enhance skills uptake following training. The training-of- trainers model (TOT) that I-TECH employs ensures a growing pool of trainers to expand access to training courses. NHTC staff are involved in all I-TECH trainings and each trainer becomes a trainer of trainers. I-TECH has transitioned six of a core of 20 NHTC-based trainers over to the MOHSS payroll, and has plans to transition six trainers each year until they are 100% absorbed into the ministry system.

NEW/REPLACEMENT NARRATIVE WITH SUBSTANTIAL CHANGES This is a continuing activity from COP09. It has one component: (1) Training of nurses in the provision of PMTCT and EID services. Background Namibia's PMTCT guidelines were revised in 2008 to include the more efficacious drug regimen recommended by WHO in 2006. The revised guidelines also recognize the importance of PMTCT follow- up and early determination of HIV status. With the National Health Training Center (NHTC), I-TECH helped to revise the PMTCT training curriculum to include Dried Blood Spot (DBS) collection and other aspects of infant follow-up such as cotrimoxizole (CTX) prophylaxis, intensive infant feeding, counseling and Provider Initiated Testing and Counseling (PITC) for children.

1) Training of nurses in PMTCT/EID. In COP09, a PMTCT/EID training-of-trainers (TOT) course was conducted for 20 participants at the NHTC. In COP10, I-TECH will continue to leverage Global Fund support to expand PMTCT/EID training. Specific I-TECH activities will include support for materials and facilitators to conduct four regional trainings for 25 participants. A total of 100 health workers will be trained. Supportive supervision/Quality Assurance: Using structured clinical support visit assessment tools, tutors from the Regional Health Training Centers will conduct quarterly clinical support visits to facilities providing PMTCT/EID services in the regions to ensure transfer of learning and to provide on-site mentorship. During these visits, two to three tutors will work as a team to assess the facility, supplies, and quality of service provision in PMTCT/EID. The five tutors (plus one driver) based at the NHTC were recruited by and receive some human resource services (e.g., payroll) from a private staffing agency. However, in line with the Namibian Labour Law, all are all directly supervised by the MOHSS and have contracts identifying the MOHSS as their formal employer (see Potentia BCN). The use of this outsourcing model to support a portion of HR services

associated with these positions has allowed the MOHSS to rapidly scale up tutoring services. A process to strengthen the capacity of the MOHSS human resource department is on-going. In COP09, this transition included the addition of an HR manager under the Directorate of Special Programmes (DSP). The transition of supervisory responsibility for these employees to the MOHSS is a first step toward the eventual full absorption and financing of these positions (either as civil servants or as contractors) by the MOHSS. Sustainability: I-TECH contributes to the sustainability of the national PMTCT program by developing and revising PMTCT/EID curricula, guidelines, M&E tools, and other related training materials. These materials strengthen the national health education system and promote training opportunities for Namibian healthcare workers in Namibia, a key objective described in the Partnership Framework. Pre- service training of University of Namibia nursing students further strengthens sustainability efforts in Namibia. I-TECH also contributes to the sustainability of the national PMTCT program by developing and revising the various PMTCT/EID curricula, guidelines, M&E tools, and other related training materials. These materials will build the systems and help ensure the delivery of high-quality, standardized PMTCT training in Namibia. Finally, through a robust quality assurance system to ensure that high-quality PMTCT services are delivered at the facility level, with regular support visits to ensure transfer of learning and to provide guidance and mentorship, the national PMTCT program will not only be sustained but will be of high quality.

NEW/REPLACEMENT NARRATIVE WITH SUBSTANTIAL CHANGES This is a continuing activity from COP09. It includes three components: (1) Training of public sector doctors and pharmacists on TB/HIV co-infection; (2) training of private nurses in the management of TB/HIV co-infection, and; (3) provision of training materials for TB/HIV training in the public sector. 1. Training of doctors and pharmacists on TB: Training by I-TECH will strengthen the abilities of public sector doctors and pharmacists to prevent, diagnose, and manage TB in the era of HIV and multiple drug resistant (MDR) TB. It is anticipated that the 2006 TB Management guidelines will be revised in 2010. These guidelines will focus on TB screening in HIV patients, testing for HIV in suspected TB cases, and provision of isoniazid preventive therapy (IPT) to all eligible HIV positive persons. It will also focus on TB infection control and the surveillance and management of drug-resistant TB. I-TECH will update the basic TB/HIV course to align with the revised 2010 guidelines, and reflect the WHO 3Is principles. Using these documents, I-TECH will conduct three basic TB courses, with 20 participants each, for a total of 60 doctors and pharmacists trained. One additional training course in TB/HIV will train 15 private doctors and pharmacists. I-TECH will also tailor this basic TB/HIV course to train health staff based in

correctional facilities. I-TECH will conduct two basic TB courses, with 20 participants each, for a total of 40 correctional staff trained. For public sector doctors and pharmacists already been trained in the management of TB, a course called "Updates in TB management: the 2010 TB guidelines," will be developed. This curriculum will be used to conduct three trainings for public sector doctors and pharmacists, with 20 participants each, for a total of 60 people trained. An advanced curriculum will be used to conduct training for individuals who have already been trained in the basic courses. 2. Training of Private Nurses: Nurses in the private sector see many patients but often lack the necessary knowledge and skills to recognize and manage TB according to the national guidelines. I-TECH will continue to train private nurses in TB/HIV and will conduct two trainings, with 20 participants each, for a total of 40 persons trained. These trainings will focus on the new TB guidelines. (Note: public sector nursing training is supported via the Global Fund).

3. Provision of TB Training Materials: I-TECH will continue to provide training materials for HIV/TB training courses offered to public sector healthcare workers. This includes trainer manuals, participant manuals, and all the relevant handouts and teaching aides. Training for public sector nurses is funded by the Global Fung, however, I-TECH will provide the training materials for the training of 250 nurses. Supportive Supervision/Quality Assurance: Quality assurance for TB/HIV will be enhanced through training and capacity building of HCW using high quality, updated TB/HIV curricula. I-TECH has six clinical mentor positions that are based in the regions. Clinical mentors provide daily in-service training for healthcare staff and will provide mentoring support to clinicians following the training in TB/HIV. HIV testing of all TB suspects and patients, and provision of IPT to all eligible HIV positive clients will continue to be promoted through on-site mentorship. Tutors from the National Health Training Centers/Regional Health Trainings Centers will provide quarterly visits to the facilities in their regions to ensure transfer of learning, provide on-site mentorship and support, identify gaps, and make recommendations for improvement. Sustainability: I-TECH's focus on technical assistance rather than service delivery promotes national ownership and reduces MOHSS dependency on external experts. I-TECH does this through support for in-service training as well as pre-service training to nursing students at the National Health Training Centre (NHTC) and University of Namibia (UNAM). Additionally, I-TECH training to doctors, pharmacists and nurses in traditional healthcare settings as well as in the correctional system will promote the use of standardized treatment guidelines in HIV, STI, and TB care and treatment. Funding through the HVTB technical area will further enhance clinicians' ability to diagnose and treat TB/HIV co-infection. The training of Namibian trainers is a prime example of I-TECH's commitment to local ownership. Training on IMAI and treatment adherence will be sustained by Namibian trainers and mentors who have received training as trainers. I-TECH support for training of lay health care workers will also promote the GRN's

task-shifting initiative and reduce workloads on doctors and nurses. Country ownership will be further enhanced as more of these local trainers are absorbed by the MOHSS as civil service staff of the National Health Training Center. The development of guidelines and revision of curricula will promote standardization of skills across the public and private healthcare sectors, and support the GRN's push to decentralize healthcare training and decision-making. As noted in other BCN, I-TECH is committed to strengthening and integrating GRN data systems. These systems play an increasingly important role in GRN decision-making and have allowed the development of evidence-based strategies, including the new National Strategic Framework (NSF).