SUBSTANTIALLY CHANGED FROM LAST YEAR The USG provides direct support to the Ministry of Health and Social Services (MOHSS) to strengthen public health infrastructure and build human resource capacity to improve access to comprehensive HIV/AIDS care.

To achieve these objectives, CDC supports the MOHSS to perform the following activities:

1. Clinical care to patients with HIV/AIDS. 2. Procurement and distribution of ARV drugs 3. PMTCT and Early Infant Diagnosis services for pregnant women and their babies 4. HIV counseling and testing. 5. Renovations of health facilities and training centers 6. Identify trainees for pre-service training in nursing, medicine, pharmacy, counseling, and laboratory sciences. 7. Combination HIV prevention, including PMTCT, ABC, male circumcision, blood safety and referrals to care and treatment. 8. Community mobilization to expand access to PMTCT, VCT, and other services. 9. Monitoring and evaluation and surveillance 10. Quality improvement in HIV/AIDS care and treatment, and in the diagnosis and treatment of related infections, including STIs and TB.

Links to the Partnership Framework This activity closely supports the USG and GRN commitments in the Partnership Framework (PF) currently under development.

In Namibia, unlike many other PEPFAR-supported countries in sub-Saharan Africa, a majority of the annual PEPFAR budget is currently structured to provide direct support to GRN and other local entities. A large portion of that direct support is provided to this partner, the MOHSS. The MOHSS currently has a mandate to manage and coordinate the national HIV/AIDS response in accordance with the current national strategic plan for HIV/AIDS (MTP 3), and the new National Strategic Framework for HIV/AIDS (NSF), which will be finalized in 2010.

PEPFAR is committed to strengthening GRN capacity and ownership, especially in the areas of human resources, and the financing and operation of national healthcare systems. In COP10, PEPFAR will emphasize the GRN's capacity to plan, oversee, manage and, eventually, finance a growing share of the commitments made in the four priority areas identified by the PF: Prevention; Treatment, Care and Support; Impact Mitigation; and Coordination and Management.

Coverage and Target population This mechanism is designed to support activities with a national scope. The public sector is structured in a three-tier hierarchy comprised of central, regional and district levels. The central level (MOHSS) has responsibility for policy formulation, regulation, planning, management and development. The regional directorates oversee 34 districts which are ultimately responsible for service delivery. With one national referral hospital, three intermediate hospitals, 30 district hospitals, 44 health centers, and more than 265 clinics, the public sector is the largest provider of healthcare. At the same time, a substantial imbalance exists in the healthcare workforce, with the majority of health professionals working in the private sector. Addressing this imbalance is a priority area for the USG.

Health Systems Strengthening In 2008, MOHSS, with support and involvement from other healthcare stakeholders (including USG), conducted a comprehensive review of the government's health and social service systems. Two areas of structural weakness within the GRN (public sector) healthcare system stood out: Unequal access to health facilities and human resources.

In COP10, USG technical assistance for the MOHSS will focus on the following areas: • Capacity building of all cadres of health workers (frontline and support)

• Strengthening of partnerships between the public and private sectors (including companies, insurance schemes, and private providers) to jointly achieve national goals and objectives for health • Strengthening civil society's ability to participate in health sector dialogue. • Organizational, financial, and management support to MOHSS to strengthen its role as steward and foster equitable resource allocation. • Expanding the decentralization process • Situation analyses and the development of engagement strategies.

Cross-Cutting Programs and Key Issues This activity's main cross cutting area is Human Resources for Health. This program will contribute to PEPFAR's broader effort to build human resource capacity by improving the capacity of MOHSS to recruit, manage and retain staff. USG support for pre and in-service service training will also build a sustainable pool of Namibian healthcare workers in nursing, medicine, pharmacy, counseling, and laboratory sciences.

Cost Efficiencies Over Time USG technical assistance in this area will support the development of transition plans. These plans should include, but not be limited to, discussions on: 1) Costs; 2) non-financial resources needed to meet program goals (e.g., human resources, equipment); 3) resource mobilization strategies, and; 4) options to institutionalize the activity within a particular sector (e.g., GRN, NGO community, for-profit, etc.).

Over time, the USG is committed to working with MOHSS to identify activities that may be absorbed completely by the GRN, that require continuing technical assistance from the USG, and that could be terminated.

Monitoring and Evaluation Plans The MOHSS will build on M&E plans and systems developed to date with PEPFAR support. All indicators will be aligned with the NSF and PEPFAR targets. Bi-annual reports will identify progress and describe any necessary changes based on available evidence.

NEW/REPLACEMENT NARRATIVE WITH SUBSTANTIAL CHANGES

This is a continuing activity from COP09. It contains one component: 1) Support for equipment and supplies for ART and palliative care facilities.

Funding under this activity supports procurement of equipment necessary to provide essential HIV- related clinical care, including tools to improve clinical monitoring. In an effort to address barriers to proper care of HIV-infected women, equipment will also be procured to improve gynecological screening and care of HIV-positive women to more adequately address HIV-related conditions such as cervical dysplasia and reproductive tract infections. Funding will further be used to replace outdated equipment in existing Integrated Management of Adolescent and Adult Illnesses (IMAI) sites as well as to procure new equipment for new sites joining the IMAI network. This includes office supplies and tools essential for IMAI palliative care rollout, including printing of IMAI patient cards and files, as well as scales, examination tables, lamps, and other standard clinical equipment.

The MOHSS is responsible for national coordination, resource mobilization, monitoring and evaluation, training, and policy development in support of all HIV and TB related services. The MOHSS manages a network of more than 300 health facilities spread out over a vast geographic area in 13 health regions and 34 health districts. The MOHSS strategy for facility-based palliative care for adult persons living with HIV and AIDS (PLWHA) is based on the WHO IMAI framework. IMAI Guidelines for Namibia were approved in COP09. Implementation will be expanded in COP10.

The procurement of new equipment will also support the national task-shifting initiative, which is central to the success of the IMAI strategy. Taking on tasks previously provided by physicians, nurses will increasingly provide palliative care including screening and treatment of patient with minor OI, Nutrition assessment and management. The nurses will also manage pre- ART clients as well as stable ART clients who have completed their first six months of ART without incident. Furthermore they will provide appropriate referrals and linkages with Community-based Health Care (CBHC) organizations.

Supportive supervision: In COP10, CDC will recruit and hire a Namibian locally employed staff (LES) as a palliative care technical advisor (see CDC HBHC budget code narrative). This advisor will work alongside MOHSS counterparts in the Directorate of Special Programmes and the Directorate of Primary Health Care. In COP10 the advisor will provide supportive supervision and other technical assistance to nurses supporting the IMAI rollout in all 13 regions of the country. The advisor will also monitor the delivery, installation and use of equipment procured by PEPFAR.

Sustainability: Support for the IMAI strategy will leverage current and past PEPFAR investments in HIV/AIDS services to benefit the broader healthcare system. Likewise, investments in capital infrastructure and equipment will expand access to HIV and non-HIV clinical services and improve patient uptake of and adherence to ART. Task-shifting and improvements in the working environment at healthcare facilities may also enhance staff morale, create workflow efficiencies that reduce workload burdens, and improve staff retention. As part of a health systems-wide assessment, the USG will work with the MOHSS and other partners to develop transition plans for the GRN to absorb, over time, most of these capital and maintenance costs.

NEW/REPLACEMENT NARRATIVE WITH SUBSTANTIAL CHANGES

This is a continuing activity from COP09. It contains six primary components: 1) Routine bio-clinical

monitoring; 2) HPV and cervical cancer screening; 3) Partial funding, human resource (HR) management and training for community counselors (CC); 4) Nutrition support to PLWHA; 5) Equipment and supplies for ART sites, and; 6) Mobile clinical services.

1. Routine bio-clinical monitoring tests. Funding will support routine bio-clinical monitoring tests (CD4, viral loads, full blood counts, liver function tests, syphilis and Hepatitis B screening, renal function tests, and other tests depending on the ART regimen) for patients at MOHSS facilities. These tests will be performed by the Namibia Institute of Pathology (NIP). In COP10, bio-clinical monitoring services will be required for approximately 90,700 ART patients. Funding will also support CD4 monitoring of non-ART patients enrolled in palliative care. These funds, which will reimburse NIP, are routed to the MOHSS rather than NIP to increase MOHSS ownership and oversight of bio-clinical monitoring costs.

The MOHSS will also begin linking clinical and laboratory data systems to allow clinicians to access the lab results as soon as they are available. This linkage will reduce turnaround time and improve data quality.

In COP10, PEPFAR will also support revisions to the national ARV treatment guidelines based on WHO recommendations. As noted in the HTXS TAN, the MOHSS may lower the ART enrollment threshold. PEPFAR will continue to work with the MOHSS to ensure a sustainable transition to the lower threshold with minimal disruptions to existing services.

2. HPV and cervical cancer screening. A pilot project will introduce cervical cancer screening in HIV- positive women enrolled in care and treatment services. The MOHSS and I-TECH will develop an on-site training course for nurses and doctors. Clinical Mentors and Nurse Tutors in the regions will pilot the training in three sites, training six nurses/doctors per site. Following the pilot training, training will be done in six additional sites for six participants at each site.

3. Community Counselors Initiative. Namibia introduced the CC program in 2004 as part of the national task-shifting initiative. Facility-based CC provide HCT (see HVCT narratives) and referral services, deliver prevention messages, and play a major role in supporting clinical PMTCT providers in antenatal clinics. In addition, CC distribute condoms, promote couples counseling, and encourage all of their clients, particularly people living with HIV and AIDS (PLWHA), to reduce high-risk sexual behaviors.

In COP10, funding for 650 CC is distributed among six program areas: PMTCT, HVAB, HVOP, HVTB, HVCT, and HTXS. CC will devote approximately 10% of their time to HTXS activities. In calendar year 2009, management and supervisory responsibility for these positions was transferred to the MOHSS from the Namibian Red Cross. This transition was required by revisions to the Namibian Labour Law, which

mandated the establishment of a clear employee-employer relationship between entities supporting contract staff and the individual staff members.

Because of this transition, COP10 funds will also partly support salaries for the following MOHSS HR staff based in the Directorate of Special Programmes (DSP): An HR manager, two HR officers, a CC assistant coordinator, and one HR administrator.

COP10 funding will also support refresher training workshops for 400 CC at the National Health Training Center, with TA from I-TECH. CC will also receive training in patient counseling and referrals for Male Circumcision, Prevention for PLWHA, and alcohol abuse.

4. Nutrition support for PLWHA on ART, including children. PEPFAR will support MOHSS systems to procure, store, monitor, and distribute nutritional supplements in line with the Food by Prescription program for approximately 2,500 PLWHA. The MOHSS will also collaborate with community based organizations to link recipients of the nutrition supplement with sustainable nutrition and income generating strategies such as gardening projects in their communities.

5. Procurement of basic clinical equipment. Funding will include tools to improve clinical monitoring, gynecological screening, and Integrated Management of Adolescent and Adult Illnesses (IMAI) services.

6. Mobile HIV services. This high-priority effort initiated in COP09 will be continued in COP10. Three MOHSS outreach teams will deliver prevention counseling, CT services, and ART services to remote areas of Namibia. Funding for these teams is divided between HVAB, HVCT and HTXS. Each mobile team will consist of a camper van, two CC for testing and mobilization, a nurse, and a driver. The teams will conduct monthly visits to remote communities.

Sustainability: Support for bio-clinical monitoring protects investments in ART drugs and helps control the emergence of drug-resistance. The IMAI strategy, including cervical cancer screening, will leverage current and past PEPFAR investments in HIV/AIDS services to benefit the broader healthcare system. Likewise, investments in capital infrastructure and equipment will expand access to HIV and non-HIV clinical services and improve patient uptake of and adherence to ART. Task-shifting, mobile services, and improvements in the working environment at healthcare facilities may also enhance staff morale, create workflow efficiencies, reduce workload burdens, and improve staff retention.

NEW/REPLACEMENT NARRATIVE WITH SUBSTANTIAL CHANGES This is a continuing activity from COP09 which includes four components: (1) Partial funding and human resource (HR) management support for community counselors (CC); (2) Procurement and distribution of HIV test kits and supplies; (3) Promotion of HIV counseling and testing (HCT) through Namibia's National HIV Testing events, and; (4) Provision of outreach-based HCT services. 1. Community Counselors. Namibia introduced the CC program in 2004 as part of the national task- shifting initiative. Facility-based CC provide HCT and referral services, deliver prevention and PMTCT messages, distribute condoms and promote couples counseling, encourage all their clients to reduce high-risk behaviors.

In COP10, funding for 650 CC is distributed across 6 program areas: PMTCT, HVAB, HVOP, HVTB, HVCT, and HTXS. CC will devote approximately 15% of their time to HVCT activities.

In calendar year 2009, management and supervisory responsibility for these positions was transferred to the MOHSS from the Namibian Red Cross. This transition was required by revisions to the Namibian Labour Law, which mandated the establishment of a clear employee-employer relationship between entities supporting contract staff and the individual staff members. Because of this transition, COP10 funds will partly support salaries for the following MOHSS staff based in the Directorate of Special Programmes (DSP): An HR manager, two HR officers, a CC assistant coordinator, and one HR administrator.

COP10 funding will also support refresher training workshops for 400 CC at the National Health Training Center, with TA from I-TECH. Lastly, COP10 funds will support MOHSS staff supervisory visits, planning meetings and an annual CC retreat.

2. Procurement of HIV Test Kits and Supplies. MOHSS will continue to purchase the following: Determine and Unigold HIV test kits (using a parallel testing algorithm) for approximately 175,000 clients at 300 MOHSS facilities; ELISA or a MOHSS-approved rapid test device for tie-breaker re-testing in discordant cases ; HIV rapid test starter packs to launch new testing sites; and rapid HIV test supplies for training CC. These will be procured and distributed by the MOHSS Central Medical Stores. MOHSS will also continue a feasibility assessment for implementing oral fluid rapid HIV testing in specific settings, including outreach and correctional settings. 3. Promotion of HCT through an Annual National HIV Testing Event. In COP09, the MOHSS held its second five day National HIV Testing Event. A total of 82,211 persons were tested and received their results. Seventy four percent (74%) of these clients were tested for the first time. While men are generally underrepresented in routine HCT services, 40% of the clients tested during this event were men. In COP 10, the MOHSS will promote two national HCT events, including a regional event on World AIDS Day.

Funding will support promotional activities in all 13 regions, including drama presentations, radio announcements, other entertainment/educational events, speeches by national and local leaders, and production and distribution of print and electronic media. Outreach-based HIV counseling and testing services will be provided during the World AIDS Day event. 4. Outreach Counseling and Testing Services. The MOHSS launched Guidelines for Outreach/Mobile Counseling and Testing Services towards the end of 2007. Given the vast distances and rural populations of Namibia, outreach/mobile services are critical to providing HIV and other public health services to all corners of the country. In COP09, funding supported procurement of four (4) mobile/outreach vans, related equipment, and personnel for a pilot phase. In COP10 PEPFAR will expanded testing services by the staff assigned to these four mobile units. Quality Assurance and Supportive Supervision: The MOHSS HCT program's commitment to quality activities is clearly demonstrated in its policy documents, as well as in the length (12 weeks) and quality of training for CC. Follow up systems are in place to monitor skills uptake and utilization following training, as are stringent internal and external quality control mechanisms for rapid HIV testing. Sustainability: The use of CC in public health facilities demonstrates the GRN's commitment to task shifting, a shared objective for the NSF and PFIP. With a critical shortage of locally trained doctors and pharmacists, CC have proven to be an effective, reliable, affordable and sustainable resource to address the human resource challenges in MOHSS facilities. Capacity building through training of locally recruited and deployed CC and health workers will ensure sustainable scale up to additional sites nationwide. The MOHSS has subcontracted a local, Namibian, training agency for the CC program. Support and supervision of CC at regional levels is conducted by nurse supervisors at health facilities. In support of sustainability objectives in the Partnership Framework, the MOHSS will continue to review its capacity to eventually absorb CC as civil servants or as contractors.

NEW/REPLACEMENT NARRATIVE WITH SUBSTANTIAL CHANGES This is a continuing activity from COP09. It includes two components: 1) Support for basic clinical equipment required to provide pediatric care services, and; 2) Support for DNA PCR tests required by Ministry of Health and Social Services' (MOHSS) Early Infant Diagnosis (EID) Program. HIV-infected children have been accommodated in HIV care and treatment services since the inception of the ART program in Namibia. The proportion of children in care has grown from 13% in the early days of PEPFAR to a high of 16% in 2006. By COP10 the rate has stabilized at 12%, a phenomenon that could be a reflection of a successful scale-up of the PMTCT program. As PMTCT program effectiveness increases, more pediatric infections will be averted and fewer children will be born HIV infected and

require treatment. The program budget for care and support is shared with HBHC, with approximately 85% supporting adult services and 15% supporting pediatrics through PDCS. 1. Clinical Equipment and Supplies. Funding under this activity supports procurement of equipment necessary to provide essential HIV-related clinical care, including tools to improve clinical monitoring and care for children. Emphasis will be put into monitoring growth and nutritional related symptoms. As such, MUAC tapes, scales and height boards will be needed to ensure all Maternal and Child Health facilities and pre-ART sites are able to monitor growth of children as part of a basic package of care. Additionally, job aides and patient education materials will be produced, printed and disseminated to improve nutritional knowledge of both health workers and clients. Funding will further be used to replace outdated equipment in existing Integrated Management of Adolescent and Adult Illnesses (IMAI) sites as well as to procure new equipment for new sites joining the IMAI network. This includes office supplies and tools essential for IMAI palliative care rollout, including printing of IMAI patient cards and files, as well as scales, examination tables, lamps, and other standard clinical equipment. The procurement of new equipment will also support the national task-shifting initiative, which is central to the success of the IMAI strategy. Taking on tasks previously provided by physicians, nurses will increasingly provide palliative care including screening and treatment of patient with minor OI, Nutrition assessment and management. The nurses will also manage pre-ART clients as well as stable ART clients who have completed their first six months of ART without incident. Furthermore they will provide appropriate referrals and linkages with Community-based Health Care (CBHC) organizations. 2. HIV DNA PCR testing for early infant diagnosis. This activity was previously funded under the PMTCT program area. Namibia was one of the first countries to roll out Dried Blood Spots and DNA PCR for EID. In 2006, the PMTCT program introduced DNA PCR for symptomatic infants and HIV-exposed infants from as early as six weeks of age. Since that time, PEPFAR funds have supported training of technicians and technologists from the Namibia Institute of Pathology (NIP) and other laboratories in PCR; purchased new equipment; financed the processing of specimens; and expanded decentralized training for health workers in the collection of DBS. This activity is critical to the survival of HIV-infected children as early diagnosis of HIV-infection facilitates early initiation of ART in the first year of life. Without any intervention, 30% of HIV-infected children will die with the first year. Additionally, exclusion of an HIV diagnosis is reassuring for parents and caregivers who have HIV-exposed children. Supportive Supervision: The CDC technical advisors for laboratory, PMTCT and quality improvement will provide day-to-day technical support and supervision to MOHSS staff engaged with these activities. As noted in other narratives, revisions to the Namibian Labour Law have driven an expansion of human resource (HR) management capacity at the MOHSS. Four new HR administrators in the Directorate for Special Programmes (DSP) will provide additional supervisory and administrative support to field staff.

Sustainability: In COP10, the MOHSS will continue to receive direct funding to reimburse NIP for DNA

PCR testing. Funding for this activity is provided to the MOHSS, rather than NIP to encourage MOHSS ownership and oversight over the program. The costs of PCR tests will gradually be absorbed by the MOHSS over the next five years. COP10 funds will support the costs of approximately 20,000 diagnostic PCR tests. This activity will also leverage resources from the Clinton Foundation, which has committed to supporting reagents for PCR in 2010.

NEW/REPLACEMENT NARRATIVE WITH SUBSTANTIAL CHANGES This is a continuing activity from COP09 which supports five components: 1) Routine bio-clinical monitoring; 2) Partial funding, human resource (HR) management and training for community counselors (CC); 3) Nutrition support to PLWHA; 4) Procurement of equipment and supplies for IMAI/IMCI and ART sites; 5) Support for mobile ART outreach.

1. Routine bio-clinical monitoring tests. Funding will support routine bio-clinical monitoring tests (CD4, viral loads, full blood counts, liver function tests, syphilis, Hepatitis B screening, renal function tests, and other tests depending on the ART regimen) for pediatric patients at MOHSS facilities. These tests will be performed by the Namibia Institute of Pathology (NIP). In COP10, bio-clinical monitoring services will be required for approximately 10,000 pediatric ART patients. Funding will also support CD4 monitoring of non-ART patients enrolled in palliative care. These funds reimburse NIP, but are routed to the MOHSS rather than NIP to increase MOHSS ownership and oversight of bio-clinical monitoring costs.

The MOHSS will also begin linking clinical and laboratory data systems to allow clinicians to access the lab results as soon as they are available. This linkage will reduce turn around time and improve data quality.

In COP10, PEPFAR will also support revisions to the national ARV treatment guidelines based on WHO recommendations. As noted in the HTXS TAN, the MOHSS may lower the ART enrollment threshold. PEPFAR will continue to work with the MOHSS to ensure a sustainable transition to the lower threshold with minimal disruptions to existing services.

2. Community Counselors Initiative. Namibia introduced the CC program in 2004 as part of the national task-shifting initiative. Facility-based CC provide HCT (see HVCT narratives) and referral services, deliver prevention messages, and play a major role in supporting clinical PMTCT providers in antenatal clinics. In addition, CC distribute condoms, promote couples counseling, and encourage all of their

clients, particularly people living with HIV and AIDS (PLWHA), to reduce high-risk sexual behaviors.

In COP10, funding for 650 CC is distributed among six program areas: PMTCT, HVAB, HVOP, HVTB, HVCT, and HTXS. CC will devote approximately 15% of their time to PDTX activities. In calendar year 2009, management and supervisory responsibility for these positions was transferred to the MOHSS from the Namibian Red Cross. This transition was required by revisions to the Namibian Labour Law, which mandated the establishment of a clear employee-employer relationship between entities supporting contract staff and the individual staff members. Because of this transition, COP10 funds will also partly support salaries for the following MOHSS staff based in the Directorate of Special Programmes (DSP): An HR manager, two HR officers, a CC assistant coordinator, and one HR administrator.

COP10 funding will also support refresher training workshops for 400 CC at the National Health Training Center, with TA from I-TECH. CC will also receive training in patient counseling and referrals for male circumcision, prevention for PLWHA, and alcohol abuse.

3. Nutrition support for PLWHA on ART, including children. PEPFAR will support MOHSS systems to procure, store, monitor, and distribute nutritional supplements in line with the Food by Prescription program for approximately 2,500 PLWHA. The MOHSS will also collaborate with community based organizations to link recipients of the nutrition supplement with sustainable nutrition and income generating strategies such as community gardening projects.

4. Procurement of basic clinical equipment. Funding will include tools to improve clinical monitoring, gynecological screening, and Integrated Management of Adolescent and Adult Illnesses (IMAI) services.

5. Mobile HIV services. This high-priority effort initiated in COP09 will be continued in COP10. Three MOHSS outreach teams will deliver prevention counseling, CT services, and ART services to remote areas of Namibia. Funding for these teams is divided between HVAB, HVCT and HTXS. Each mobile team will consist of a camper van, two CC for testing and mobilization, a nurse, and a driver. The teams will conduct monthly visits to remote communities.

Supportive Supervision: The CDC technical advisors for laboratory, PMTCT and quality improvement will provide day-to-day technical support and supervision to MOHSS staff engaged with these activities. As noted in other narratives, revisions to the Namibian Labour Law have driven an expansion of human resource (HR) management capacity at the MOHSS. Four new HR administrators in the Directorate for Special Programmes (DSP) will provide additional supervisory and administrative support to field staff.

Sustainability: Support for bio-clinical monitoring protects investments in ART drugs and helps control

the emergence of drug-resistance. The IMAI strategy, including cervical cancer screening, will leverage current and past PEPFAR investments in HIV/AIDS services to benefit the broader healthcare system. Likewise, investments in capital infrastructure and equipment will expand access to HIV and non-HIV clinical services and improve patient uptake of and adherence to ART. Task-shifting, mobile services, and improvements in the working environment at healthcare facilities may also enhance staff morale, create workflow efficiencies, reduce workload burdens, and improve staff retention.

NEW/REPLACEMENT NARRATIVE WITH SUBSTANTIAL CHANGES This is a continuing activity from COP09. It included four components: (1) Support for the Ministry of Health and Social Services (MOHSS) RM&E Program; (2) support for the management of MOHSS Health Information Systems (HIS) and national database server; (3) support for an evaluation of the national ART program, and; (4) support for the 2010 sentinel surveillance survey in antenatal clinics (ANC). 1. RM&E Program Support: The following items will be procured by MOHSS to expand and enhance the capture, processing, and dissemination of routine data produced by programs within the national HIV/AIDS response: • Computers, monitors, printers, and uninterrupted power supplies will be procured for all new data clerks and HIS officers in all ART, PMTCT, CT, and TB clinic sites. The COP10 budget will also include funds for repairs and replacement parts for computer systems which are identified by MoHSS staff. • Software (including antivirus) upgrades and 65 memory sticks. • Connectivity options will be assessed and technical assistance will be provided to implement appropriate internet connectivity tools for secure email access for all facility-based and regional informatics personnel. • In COP07 patient care books were updated to conform to WHO standards. COP10 will support production of approximately 20,000 patient books. • Three laptop computers and 3G internet connectivity devices will be purchased to facilitate training and travel by RM&E staff. • Support routine printing of necessary patient record forms and site registers for collection and dissemination of routine ART/PMTCT/CT/TB data. • Printing and dissemination of the RM&E Annual Report. • COP 10 will support the provision of office furniture for continued expansion of RM&E activities at the sub-national level. • PEPFAR will support travel for RM&E staff to conduct supportive supervision, mentoring, data collection

and other reporting. 2. MOHSS Health Information Systems (HIS) and National Database Server Support: Technical assistance and upgrades for HIS will be provided at the national and sub-national level. Refresher trainings will be provided for all sub-national data clerks. In addition, MOHSS will support a consultant to continue the rollout of a the district health information system, conduct trainings, and assist with the development of a strategy to ensure the efficient and effective use of data collected at all levels of the MOHSS. In addition, continuing training and support for the implementation of a national database server. This server will be based in the Officer of the Prime Minister and house integrated healthcare data from across the MOHSS system. 3. Evaluation of ART program. MOHSS will plan and conduct a national ART program evaluation to assess the quality of care and outcomes of its HIV care and treatment activities. 4. ANC Sentinel Surveillance 2010: Every two years the MOHSS conducts a sentinel HIV survey in ANC sites to estimate HIV prevalence among pregnant women. COP10 funding will support planning, tool development, training, site selection, supportive supervision, data analysis, and printing and dissemination of the final report. Supportive supervision/Quality Assurance: Supportive supervision for quality assurance by MOHSS and USG staff will be a focus for COP10. As improvements and modifications are implemented with data systems and as more staff are trained, a structured schedule of site visits and other communication will be implemented.

Sustainability: Sustainability is achieved through support for training courses and ongoing hands-on mentoring of RM&E staff. In line with the strategic objectives outlined in the Partnership Framework, MOHSS will also conduct an assessment of its current HIS capacity. This assessment will describe gaps in the data collection system, and areas where HIS systems may be better integrated (within the health sector and across other sectors, e.g., human resources). The assessments will inform the development of an MOHSS transition plan to describe how and when responsibilities may be absorbed, and how and where USG technical assistance should be provided.

NEW/REPLACEMENT NARRATIVE WITH SUBSTANTIAL CHANGES

This is a continuing activity from COP09. It includes one component: 1) Support for scholarships and bursaries for Namibian students in the healthcare sciences.

PEPFAR has provided scholarship and bursary support to the MOHSS since COP05. A total of 943 bursaries have been awarded for Namibians to study medicine, nursing, pharmacy, social work, public health, and other allied health fields. Some of these bursaries have supported students to attend educational programs abroad. However, an increasing number of bursaries have supported training in Namibia. Inadequate human resource capacity is among the leading obstacles to the development and sustainability of HIV/AIDS-related health services in Namibia. The USG has recognized pre-service training as instrumental in scaling up and sustaining the national HIV/AIDS response, and to strengthening the overall healthcare system. Critical human resources gaps exist at all facility levels of the healthcare system, from the national administration to local facilities. The lack of pre-service training institutions for doctors and pharmacists in Namibia, coupled with limited local training opportunities for other allied health professionals, has contributed to a chronic shortage of health professionals. In 2007, the vacancy rate in the Ministry of Health and Social Services (MOHSS) was 35% for doctors, 22% for registered nurses, 26% for enrolled nurses, and 41% for pharmacists. Since COP05, PEPFAR has made substantial investments to build local training capacity in Namibia. Other non-PEPFAR resources from the USG are leveraged to improve Namibia's weak secondary education system to prepare students for health careers. This includes support from the Millennium Challenge Account for textbooks and the Ambassador's Scholarship Program that support scholarships for young girls to attend grades 8 through 12. COP10 will support bursaries for a minimum of 400 Namibians to train as doctors, pharmacists, pharmacy assistants, nurses, enrolled nurses, laboratory technologists, social workers, public health administrators, epidemiologists, and nutritionists in Namibia, South Africa, Kenya, and elsewhere. Students are technically bonded to serve the MOHSS upon completion of their studies, however enforcement of these bonds is lax. In COP10, the USG will lead an evaluation of returned scholarship recipients to quantify attrition rates and identify methods to improve retention within the public healthcare sector. As noted above, PEPFAR support for local educational institutions has permitted more Namibians to remain in Namibia for pre-service training. These pre-service programs include the nursing and pharmacy training programs at the National Health Training Center (NHTC) and University of Namibia (UNAM), the medical technology training program at the Polytechnic of Namibia (PoN), and the public health program at UNAM. 1. Nursing and Pharmacy Training. To fill urgently needed nursing and pharmacy positions, this activity will support MOHSS plans to increase the output of enrolled nurses and pharmacy assistants from the NHTC, who can be trained in two years instead of four years, and for registered nurses at UNAM. These positions are urgently needed as task-shifting and Integrated Management of Adult Illness (IMAI) continues to be rolled out. In COP10, some of the students enrolled in the nursing program are former

community counselors. PEPFAR will promote the "graduation" from lay community counselor to professional healthcare worker in its broader strategy to strengthen the career ladder at all levels of the health system. 2. Medical Technology Training. PEPFAR will support bursaries for students in the laboratory technologist program at the PoN, which began enrolling students in January 2008. 3. Public Health Training. Bursaries will also support students who enroll in the PEPFAR-supported MPH program in public health leadership and certificate programs in monitoring and evaluation and nutrition. Supportive Supervision: PEPFAR will work with the MOHSS' Division of Public Policies and Human Resources Development (PPHRD) to track students receiving bursaries and assess the impact of returning students on the healthcare system. This assessment process will also examine the bursary program retrospectively to determine the number of students who ultimately took jobs within the public healthcare sector. This retrospective review will quantify attrition rates and determine the extent of the healthcare worker "brain drain" from the public to the private sectors in Namibia. Sustainability: The assessments described above will contribute to a better understanding of the impact PEPFAR-supported bursaries have had on the healthcare shortage in Namibia. The results of this evaluation will directly support the Partnership Framework emphasis on Human Resources for Health. Country ownership of the bursary program will be promoted through technical assistance to build HR capacity within the MOHSS to manage the program.

NEW/REPLACEMENT NARRATIVE WITH SUBSTANTIAL CHANGES This is a continuing activity from COP09. It includes one primary component: (1) The provision of supplies, equipment, and commodities for male circumcision. This activity is also linked to staffing and training narratives under CIRC (see Potentia and I-TECH). As the demand for male circumcision (MC) increases in Namibia, PEPFAR will support the MOHSS to ensure that appropriate supplies, equipment, and commodities are available. These supplies and commodities may include, but will not be limited to, surgical equipment, sterile equipment, local anesthetic, patient education materials and training curricula. The national MC task force, that includes representatives from Ministry of Health and Social Services (MOHSS), USG, UNAIDS, and other non-governmental organizations, will work closely with the MOHSS Central Medical Stores to order, stock, and distribute the appropriate supplies, commodities, and equipment. A distribution plan will be aligned with the roll-out plan for MC services. In September 2009, Namibia initiated pilot MC activities for adults (18 years or older) in five settings in Namibia. In COP10, MC activities will be expanded to all of Namibia's 13 regions.

In addition, traditional circumcisers perform circumcisions on males of any age, but primarily focus on neonates through children aged three years. The MOHSS invited traditional circumcisers to the MC stakeholders meeting held in 2008 and remains interested in working with this group to train, and possibly certify and register, traditional male circumcisers. The MOHSS has also expressed an interest in distributing a male circumcision "supply pack" to traditional circumcisers in an attempt to improve safety and sanitary conditions. Training for traditional providers would accompany and eventual supply pack distribution. Supportive Supervision: As noted in the Potentia narratives for CIRC, a national MC coordinator will be supported in COP10 to provide supportive supervision, monitoring and evaluation, and training to the specialist physicians and nurses who will perform MC.

Sustainability: COP10 is the third year of funding for Male Circumcision (MC) activities in Namibia. However, MC activities have not been rolled out beyond five pilot sites as the Namibian government is in the process of approving a MC policy. PEPFAR will continue to provide technical assistance and support for management and medical personnel as well as capacity building of existing personnel in this important area. PEPFAR's initial financial support for this activity will help strengthen the MOHSS Central Medical Stores to procure and distribute MC supplies and commodities. Based on the demand of services, MOHSS may need to supplement the PEPFAR investment in this area to cover any budgetary gaps. In the National Strategic Framework and in the Partnership Framework, the MOHSS has identified MC as a priority and has committed to supporting it to scale. In line with these commitments, and based on trends in public uptake of MC services, the PEPFAR will work with the MOHSS to develop a detailed sustainability plan for MC.

NEW/REPLACEMENT NARRATIVE WITH SUBSTANTIAL CHANGES

This is a continuing activity from COP09. It contains one component: (1) Partial funding and human resource (HR) management support for community counselors (CC).

1. Community Counselors. Namibia introduced the CC program in 2004 as part of the national task- shifting initiative. Facility-based CC provide HCT and referral services, delivery prevention messages to HIV-negative women and others, and play a major role in supporting clinical PMTCT providers in antenatal clinics. In addition, CC will distribute condoms and promote couples counseling and encourage all their clients, but particularly people living with HIV and AIDS (PLWHA), to reduce high-risk behaviors

through abstinence and being faithful to one partner. All activities will incorporate gender messaging in compliance with Namibia's male norms initiative which seeks to address cultural norms that factor into HIV transmission, including lack of health care seeking behavior by men, multiple sex partners, transactional and trans-generational sex, power inequities between men and women, and alcohol abuse. CC are also the primary personnel at health sites responsible for HCT services (see HVCT TAN and associated BCN).

In COP10, funding for 650 CC is distributed among six program areas: PMTCT, HVAB, HVOP, HVTB, HVCT, and HTXS. CC will devote approximately 50% of their time to HVAB activities. In calendar year 2009, management and supervisory responsibility for these positions was transferred to the MOHSS from the Namibian Red Cross. This transition was required by revisions to the Namibian Labour Law, which mandated the establishment of a clear employee-employer relationship between entities supporting contract staff and the individual staff members.

Because of this transition, COP10 funds will also partly support salaries for the following MOHSS HR staff based in the Directorate of Special Programmes (DSP): An HR manager, two HR officers, a CC assistant coordinator, and one HR administrator.

COP10 funding will also support refresher training workshops for 400 CC at the National Health Training Center, with TA from I-TECH. CC will also receive training in counseling and referrals for Male Circumcision, Prevention for PLWHA, and alcohol abuse.

Lastly, COP10 funds will support supervisory visits by MOHSS staff; planning meetings and an annual retreat for CC.

Supportive supervision: The MOHSS now provides additional management oversight and supervision for contract staff.

Sustainability: As noted above, the MOHSS has expanded the duties of the Deputy Director of the (DSP) to include direct management and administration of six contract staff and the CC cadre. This transition represents an important step toward the eventual full absorption and financing of these staff - either as civil servants or as contractors - by the MOHSS. Long-term cost savings are being achieved through the focus on recruiting and deploying staff within their own communities. CC retention rates are also high, suggesting a high level of morale among this cadre of lay healthcare workers. Also of note, several CC have recently "graduated" to enroll in nursing school. Similar transitions will be encouraged throughout the task-shifting initiative.

NEW/REPLACEMENT NARRATIVE WITH SUBSTANTIAL CHANGES

This is a continuing activity from COP09. It contains four primary components: (1) Partial funding, human resource (HR) management and training for community counselors (CC); (2) Condom procurement; (3) Support for the Ministry of Health and Social Services' (MOHSS) Coalition on Responsible Drinking (CORD), and; (4) Partial support for outreach teams to deliver prevention and testing services to remote communities.

1) Community Counselors. Namibia introduced the CC program in 2004 as part of the national task- shifting initiative. Facility-based CC provide HCT (see HVCT narratives) and referral services, deliver prevention messages, and play a major role in supporting clinical PMTCT providers in antenatal clinics. In addition, CC will distribute condoms, promote couples counseling, and encourage all of their clients, but particularly people living with HIV and AIDS (PLWHA), to reduce high-risk behaviors through abstinence and faithfulness to one partner. All activities will incorporate gender messaging linked to Namibia's male norms initiative which seeks to address cultural norms that factor into HIV transmission, including lack of health care seeking behavior by men, multiple sex partners, transactional and trans- generational sex, power inequities between men and women, and alcohol abuse.

In COP10, funding for 650 CC is distributed among six program areas: PMTCT, HVAB, HVOP, HVTB, HVCT, and HTXS. CC will devote approximately 10% of their time to HVOP activities. In calendar year 2009, management and supervisory responsibility for these positions was transferred to the MOHSS from the Namibian Red Cross. This transition was required by revisions to the Namibian Labour Law, which mandated the establishment of a clear employee-employer relationship between entities supporting contract staff and the individual staff members.

Because of this transition, COP10 funds will also partly support salaries for the following MOHSS HR staff based in the Directorate of Special Programmes (DSP): An HR manager, two HR officers, a CC assistant coordinator, and one HR administrator.

COP10 funding will also support refresher training workshops for 400 CC at the National Health Training Center, with TA from I-TECH. CC will also receive training in patient counseling and referrals for Male Circumcision, Prevention for PLWHA, and alcohol abuse.

Lastly, COP10 funds will support supervisory visits by MOHSS staff; planning meetings and an annual

retreat for CC.

2) Condom Procurement. The majority of condoms in Namibia are financed by the Global Fund (GF). Condoms are distributed free of charge to health facilities and to the community. In COP10, Namibia plans to procure over 20 million condoms. The GF is expected to fund 13 million condoms, PEPFAR six million, and the Namibian government one million. USG support will emphasize sub-national logistics and distribution strategies to improve access to condoms in remote areas.

3. Expansion of CORD. USG funds will continue to support the expansion of the MOHSS Directorate of Social Welfare's Coalition on Responsible Drinking (CORD). CORD incorporates media messaging and works with community, business, and health partners, as well as shebeens (bars) and breweries to reduce alcohol abuse, a major driver of the HIV epidemic in Namibia. CORD will be rolled out to five additional regions and will use these funds to educate business owners and the general public about the association between alcohol consumption, high-risk sexual behavior, and HIV transmission.

4. Outreach Team. This high-priority effort initiated in COP09 will be continued in COP10. Three MOHSS outreach teams will deliver prevention counseling, CT services, and ART services to remote areas of Namibia. Funding for these teams is divided between HVAB, HVCT and HTXS. Each mobile team will consist of a camper van, two CC for testing and mobilization, a nurse, and a driver. The teams will conduct monthly visits to remote communities (e.g. the first Thursday of each month) and will work with community-based field officers, community leaders, and local radio stations to promote each outreach visit.

CT services will be implemented first (see HVCT narrative), with an emphasis on prevention messaging. Costs per client, success in reaching first-time testers, ability to link positive clients to treatment, and community receptiveness will be evaluated in COP10. If the outreach teams are able to effectively deliver these services, other components may be added, including ART, TB screening and DOT, PMTCT, case management, and alcohol counseling and referrals.

Supportive supervision: The MOHSS now provides additional management oversight and supervision for contract staff.

Sustainability: As noted above, the MOHSS has expanded the duties of the Deputy Director of the (DSP) to include direct management and administration of six contract staff and the CC cadre. This transition represents an important step toward the eventual full absorption and financing of these staff - either as civil servants or as contractors - by the MOHSS. Long-term cost savings are being achieved through the focus on recruiting and deploying staff within their own communities. CC retention rates are also high,

suggesting a high level of morale among this cadre of lay healthcare workers. Also of note, several CCs have recently "graduated" to enroll in nursing school. Similar transitions will be encouraged throughout the task-shifting initiative.

NEW/REPLACEMENT NARRATIVE WITH SUBSTANTIAL CHANGES

This is a continuity activity from COP 2009. It supports seven components: (1) Partial funding and management support for community counselors (CC); (2) procurement of routine supplies and equipment; (3) PMTCT training for traditional birth attendants (TBA); (4) support for a PMTCT information, education, and communication (IEC) campaign; (5) support for case managers to improve follow-up of mother-infant pairs; (6) provision of nutritional supplementation for persons living with HIV/AIDS (PLWHA), and; (7) management and administration of contract staff.

1. Community Counselors. In COP10, funding for 650 CC, who dedicate part of their time to this activity is distributed among six program areas: PMTCT, HVAB, HVOP, HVTB, HVCT, and HTXS. CC will devote approximately 10% of their time to PMTCT. In 2009, management and supervisory responsibility for these positions was transferred to the MOHSS from the Namibian Red Cross. This transition was required by revisions to the Namibian Labour Law, which mandated the establishment of a clear employee-employer relationship between entities supporting contract staff and the individual staff members.

Namibia introduced the CC program in 2004 as part of the national task-shifting initiative. Facility-based CC provide HCT and referral services, provide prevention messages to HIV-negative women, and play a major role in supporting clinical PMTCT providers in antenatal clinics. In addition, CC also provide couples counseling services and support patients to address the difficult and often contentious issue of discordance between couples.

2. Procurement of supplies and equipment. In COP 10, PEPFAR will support the printing and distribution of revised ANC and maternity registers, as well as monthly ANC and Labor and Delivery summary forms. In addition, hemoglobinometers will be procured to support anemia monitoring for women on AZT-containing regimens. Clinic furniture and equipment for new PMTCT sites will also be procured. Support will also assist in printing and dissemination of the new national PMTCT guidelines.

3. Training for Traditional Birth Attendants (TBA). Approximately 25% of deliveries in Namibia occur outside of a health facility and are conducted by traditional birth attendants (TBA). While it is critical to engage with, and motivate these TBA to refer pregnant women for a skilled birth attendant, some women in remote areas find it hard to present to maternity for delivery. Training on PMTCT, HIV prevention, reproductive health, and referrals will be provided to 80 TBA in COP10.

4. Support for an IEC campaign promoting PMTCT. A national educational campaign by the Directorate of Primary Health Care to promote PMTCT services in collaboration with the Ministry of Information, Communication and Technology (MICT) will continue in COP10. Funding will be provided to develop, produce, and disseminate PMTCT educational materials for strategic communications in the clinical setting, including the promotion of male involvement. Materials will be produced in local languages as appropriate.

5. Case Managers (CM). COP10 will continue for support 21 case managers who will provide services in eight program areas (HBHC, HVAB, HTXS, PDTX, HVOP, PDCS, and HVTB), including MTCT. Through an intervention/service plan CM will address and reassess the issues that are putting clients at risk of defaulting on treatment or engaging in risky behaviors. In support of MTCT objectives, CM will: a. Coordinate resources for clients, including facilitation of psycho-social support groups for PLWHA caregivers. b. Assist with treatment defaulter tracing, mother-baby pair follow-up and referral to EID, Cotrimoxizole, and other services. c. Counseling patients on adherence, prevention with positives, Family Planning (FP), STI services and disclosure/partner referral d. Referrals to other health and social services (e.g., FP, STI services, drug/alcohol treatment and domestic violence) e. Encourage men to seek services and to support their partners and children in doing the same.

6. Management and administration of contract staff. In early 2009, the passage of a new Labour Law required the MOHSS and other employers to revise contractual mechanisms to shift legal responsibility for contract staff from Potentia, a private HR services firm, to the MOHSS. This shift was required to establish a clear employee-employer relationship with the MOHSS. Potentia will continue to provide some HR services (e.g., payroll) for CM and six MOHSS training staff, but overall responsibility for supervision and management will be assured by the MOHSS Directorate of Special Programmes (DSP).

7. Nutritional supplementation for PLWHA. Improving maternal nutritional status and supporting the nutritional status of pregnant and lactating women will be provided to meet the needs of a minimum of 10% of all HIV-positive pregnant women.

Sustainability: This activity will leverage new USG centrally funded food supplementation activities to be undertaken in public health facilities. The activity will also leverage support from UNICEF and the Clinton Foundation. As noted above, the MOHSS has expanded the duties of the Deputy Director of the (DSP) to include direct management and administration of six contract staff and the CC cadre. This transition represents an important step toward the eventual full absorption and financing of these staff - either as civil servants or as contractors - by the MOHSS.

NEW/REPLACEMENT NARRATIVE WITH SUBSTANTIAL CHANGES This is a continuing activity which includes one component: funding support to procure FDA-approved ARVs through the Ministry of Health and Social Services' (MOHSS) Central Medical Stores (CMS). The MOHSS CMS procures and distributes all public sector ARVs in Namibia. Through a single procurement structure, the CMS uses funds from the MOHSS, the USG, the Global Fund, and other partners, including the Clinton Foundation, to simplify procurement and maximize purchasing power. In 2007, the Government of Namibia (GRN) commissioned a costing exercise from the European Commission to project future HIV/AIDS costs, including ARVs. Currently the GRN finances about 35% of ARVs and this is projected to increase to 43% in 2010 and 55% in 2015. As described in COP09, the Namibia PEPFAR team opted to temporarily remove $2.5 million from the MOHSS' ARV funding in COP09. USG will restore these funds once a Partnership Framework (PF) is signed between the US and the GRN, now scheduled for sometime in calendar year 2010. As of June 2009, 73,674 adult and pediatric patients were receiving treatment in 141 sites, up from 101 sites as of the end of September 2008. Approximately 88% were adults and 12% were children. ART services remain congested at a number of sites, and the continuing focus of the national ART program is to: 1) Decentralize care and treatment for both adults and children. 2) Focus on quality of care and treatment, including promoting consumer involvement in quality of care issues. 3) Incorporate prevention and family planning messages into treatment 4) Improve "user friendliness" of ART services, 5) Improve linkages to TB and PMTCT services as well as with community-based organizations, 6) Roll-out prevention with positives strategies nationwide (excepting three control sites involved in the PwP pilot study), and 7) Increase the involvement of people living with HIV/AIDS (PLWHA) in palliative care and/or adherence

support programs to strengthen the adherence strategy. Namibia has standardized first and second-line regimens. Currently, 71% of adults on first-line regimens are currently on stavudine/lamivudine/nevirapine (d4T/3TC/NVP) or zidovudine/lamivudine/nevirapine (AZT/3TC/NVP), 21% are on stavudine/lamivudine/efavirenz (d4T/3TC/EFV) or AZT/3TC/EFV, and 8% are on a tenofovir (TDF) containing regimen. Only 2.4% of patients on ART were on second-line regimens as at end of June 2009. New national treatment guidelines were released in April 2007 which recommended AZT-based HAART regimen and instead of the previous use of D4T; due to d4T toxicity. Namibia is poised to revise its treatment guidelines to align with the 2009 WHO revised guidelines expected at the end of 2009. The MOHSS Technical Advisory Committee (TAC) has already recommended a move to TDF-based first line and a lowering of the threshold for initiating ART to 350. Both these recommendations have been subjected to a costing analysis. The TAC now awaits MOHSS senior management and their partners to review financial implications of the proposed two new major changes, before making a final decision on the way forward. In 2007, a procurement plan for 2007 was developed and implemented by the MOHSS, the USG and the Global Fund to consolidate drug procurement through the CMS. Currently, 83% of the drugs procured are FDA-approved and 17% are not FDA-approved. Funds from MOHSS and other donors will continue to be used to procure non-FDA-approved products. The supply chain for ARVs and related drugs works well and cost-effectively in Namibia, with state-of-the-art pharmacy information system and inventory practices that have virtually eliminated ARV stock-outs. Sustainability: With USG support, the MOHSS has enhanced its considerable technical capacity to lead all aspects of its national treatment program, from care and treatment guidelines to pharmaceutical management, forecasting, procurement and supply chain management. The GRN is well positioned to sustain this leadership into the future. The GRN recognizes that its absorption of ARV costs is an important step toward sustainability of its treatment program, and has been increasing the portion of ARV costs covered by MOHSS funding over time, while USG contributions have declined. The Clinton Foundation/UNITAID will continue to work with CMS to negotiate substantial price reductions for CMS for pediatric and second-line drugs, and signed a multi-year memorandum of understanding with the MOHSS to continue to assist CMS with bringing down drug costs in 2008. These negotiations have resulted in the addition of low-cost pediatric fixed dose combination (FDCs) to the CMS formulary, which is likely to substantially improve adherence and efficacy and reduce wastage from previous regimens which involved messy and difficult-to-measure syrups.

NEW/REPLACEMENT NARRATIVE WITH SUBSTANTIAL CHANGES

This is a continuing activity from COP09. It includes four components: (1) Partial funding and human resource (HR) management support for community counselors (CC) to ensure HIV testing of tuberculosis (TB) patients; (2) procurement of HIV rapid test kits for testing of TB patients; (3) support for laboratory diagnosis and bi-clinical monitoring for TB, and; (4) support TB drug resistance surveillance..

1. Community Counselors. Namibia introduced the CC program in 2004 as part of the national task- shifting initiative. Facility-based CC provide HCT and referral services, deliver prevention and PMTCT messages to HIV-negative women and others, distribute condoms and promote couples counseling, encourage all their clients, but particularly people living with HIV and AIDS (PLWHA), to reduce high-risk behaviors through abstinence and being faithful to one partner. All activities will incorporate gender messaging in compliance with Namibia's male norms initiative which seeks to address cultural norms that factor into HIV transmission, including lack of health care seeking behavior by men, multiple sex partners, transactional and trans-generational sex, power inequities between men and women, and alcohol abuse. CC are also the primary personnel at health sites responsible for HCT services (see HVCT TAN and associated BCN).

In COP10, funding for 650 CC is distributed across six program areas: PMTCT, HVAB, HVOP, HVTB, HVCT, and HTXS. CC will devote approximately 10% of their time to HVTB activities, which will include HIV testing and counseling to TB patients. In 2007, 54% of TB patients were tested for HIV; 59% of these TB patients were HIV positive. In CO09 approximately 80% of TB patients received an HIV test.

In calendar year 2009, management and supervisory responsibility for these positions was transferred to the MOHSS from the Namibian Red Cross. This transition was required by revisions to the Namibian Labour Law, which mandated the establishment of a clear employee-employer relationship between entities supporting contract staff and the individual staff members.

Because of this transition, COP10 funds will also partly support salaries for the following MOHSS HR staff based in the Directorate of Special Programmes (DSP): An HR manager, two HR officers, a CC assistant coordinator, and one HR administrator.

COP10 funding will also support refresher training workshops for 400 CC at the National Health Training Center, with TA from I-TECH. CC will also receive training in counseling and referrals for Male Circumcision, Prevention for PLWHA, and alcohol abuse.

Lastly, COP10 funds will support supervisory visits by MOHSS staff; planning meetings and an annual

retreat for CC.

2. Procurement of HIV Test Kits and Supplies for TB patients and suspects. MOHSS will continue to purchase the following: Determine and Unigold HIV test kits (using a parallel testing algorithm) for approximately 50,000 TB patients and suspects at 250 MOHSS facilities; ELISA or an MOHSS-approved rapid test device for tie-breaker re-testing in cases of discordance; HIV rapid test starter packs to launch new testing sites; and rapid HIV test supplies for training CC. These kits and supplies will be procured and distributed by the MOHSS Central Medical Stores.

3. Lab diagnosis and bio-clinical monitoring for TB. In 2008, 268 cases of all forms of drug resistant TB were reported. Of those, 23 cases were diagnosed as Extensively Drug Resistant (XDR) TB, 201 cases were diagnosed as Multi Drug Resistant (MDR), and 44 were diagnosed as "poly resistant." In COP10, the Namibia Institute of Pathology (NIP) will continue to provide support aggressive TB case finding through diagnostic and bio-clinical monitoring services to MOHSS.

4. TB Drug Resistance Surveillance. In COP10, MOHSS will expand TB drug resistance surveillance with technical assistance from CDC and laboratory support from NIP.

Supportive supervision: As noted above, the MOHSS now provides additional management oversight and supervision for contract staff.

Sustainability: The MOHSS has expanded the duties of the Deputy Director of the (DSP) to include direct management and administration of six contract staff and the CC cadre. This transition represents an important step toward the eventual full absorption and financing of these staff - either as civil servants or as contractors - by the MOHSS. Long-term cost savings are being achieved through the focus on recruiting and deploying staff within their own communities. CC retention rates are also high, suggesting a high level of morale among this cadre of lay healthcare workers. Also of note, several CCs have recently "graduated" to enroll in nursing school. Similar transitions will be encouraged throughout the task-shifting initiative.