PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
NEW/REPLACEMENT NARRATIVE
This activity includes one component: renovation of an ART and antenatal clinic to expand capacity to care
for HIV-impacted clients and to build infrastructure.
Because this activity will impact both adult and pediatric treatment, the funding amount of $488,750
represents 85% of renovation costs; the remaining 15% ($86,250) is reflected in the PDTX program area.
The Regional Procurement Support Office (RPSO) in Frankfurt will continue to assist USG Namibia by
providing high quality technical guidance and required contracting authorities mandatory by USG regulation.
Through RPSO, the USG secures the services of local construction contractors to effect renovations at
select Ministry of Health and Social Services (MOHSS) sites throughout Namibia in the implementation of
HIV prevention, care and treatment services.
Facility renovation in Namibia is crucial for both provision of ART and PMTCT as well as training of future
ART providers. Many MOHSS health facilities are in need of basic space in the outpatient department to
accommodate the large influx of patients seeking ART. Several MOHSS sites are providing ART in
inappropriate and unsafe environments, such as unused space on tuberculosis wards and operating
theatres. With FY 2009 COP, CDC/Namibia will seek to secure a full-time infection control technical advisor
who will have, among other duties, the responsibility of ensuring that all future renovations maximize
structural interventions that can prevent transmission of TB. Even when not the principal funder of a
renovation or construction project, CDC/Namibia frequently provides equipment, supplies and technical
assistance and is called in by the GRN to serve on the planning committees for such projects.
The USG will continue to collaborate with the MOHSS, the Ministry of Works, the Global Fund, and other
donors to determine priority sites for renovation and the appropriate funding source for each. Renovation of
ART sites may not always result in more patients on ART, but will result in improved quality of services,
improved infection control, and reduced waiting times.
The Government of the Republic of Namibia recognizes that investing in building of health facility
infrastructure should increasingly be its responsibility, and not that of donors. To that end, PEPFAR will
decrease its commitment to facility renovations over the coming years. FY 2007 COP funds supported five
renovations, FY 2008 COP funds will support two renovations, and FY 2009 COP funds will only support
one renovation.
New/Continuing Activity: Continuing Activity
Continuing Activity: 16209
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
16209 3842.08 Department of Regional 7378 2321.08 $1,000,000
State / African Procurement
Affairs Support
Office/Frankfurt
8088 3842.07 Department of Regional 4690 2321.07 $1,515,090
3842 3842.06 HHS/Centers for Regional 3119 2321.06 $703,435
Disease Control & Procurement
Prevention Support
Emphasis Areas
Construction/Renovation
Human Capacity Development
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Program Budget Code: 10 - PDCS Care: Pediatric Care and Support
Total Planned Funding for Program Budget Code: $2,845,454
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
In FY 08, the projected number of HIV-infected children less than 15 years of age in Namibia was 10,414. Of this number, 3,337
are in chronic HIV care and 7,077 are on ART; just under 13% (7,077/56,054) of all clients on ART are children. Namibia was one
of the first countries to implement an early infant diagnosis (EID) program, rolling out HIV DNA PCR testing in early 2006 to test
exposed infants at 6 weeks. The use of antibody testing is encouraged for older children from the age of 12 months; by this age,
most HIV-exposed children will have lost transplacentally acquired maternal anti-HIV antibodies. If these children have not been
breastfed in the preceding 3 months, a negative result will reliably exclude HIV infection. The EID algorithm for Namibia is being
revised to lower the age to offer an HIV antibody test from 12 to 9 months, in line with WHO recommendations.
Training of health care workers in Dried Blood Spot (DBS) collection technique has been rolled out with PEPFAR support. DBS
training is provided by I-TECH in collaboration with the MOHSS National Health Training Center (NHTC); I-TECH and NHTC
conducts most HIV-related training on behalf of the MOHSS. With USG support, the Namibia Institute of Pathology (NIP), a fee-for
-service parastatal, provides lab services to the MOHSS for all diagnostic and bio-clinical monitoring tests associated with
providing care and treatment to HIV infected adults and children. NIP supports DNA PCR testing testing of all exposed children.
With PEPFAR funds, the molecular lab at NIP was renovated and operational in 2005. PEPFAR also support the cost of a lab
technician to perform the HIV DNA PCR tests, as well as a CDC lab scientist who provides training and technical assistance for
quality DNA PCR testing. Since the beginning of the EID program, 17,870 of HIV DNA PCR tests were performed, and of these,
11.1% of first tests were positive. In FY08, 8,835 DNA PCR tests were performed; 10.6% of these tests were positive. Namibian
women overwhelmingly practice breastfeeding, with most HIV positive women (at least 90%) in labor wards expressing a desire to
breastfeed. As a result, the majority of infants who test HIV negative on a PCR at 6 weeks or during any subsequent period while
still breastfeeding are subjected to a second DNA PCR test at least 2 months after their last breastfeeding.
Linking children from EID to care and treatment has been a challenge. The program will intensify follow-up of HIV-exposed
children identified through PMTCT. The program will intensify provider initiated testing and counseling (PITC) for all children
presenting to outpatient and inpatient departments, utilizing immunization services and growth monitoring in under-5 clinics. With
the PITC approach, all mothers of unknown status bringing their children to health facilities will be offered rapid testing to
determine their own status as well as the HIV-exposure status of their babies. When the mother does not wish to take the HIV
test, a rapid test will be offered to determine the child's status. If the child is under 18 months of age and positive, a DNA PCR
test can then be performed to definitively determine HIV infection. In support of early identification of HIV-exposed children
needing care, the MOHSS' Directorate of Primary Health Care leveraged UNICEF support to revise the Child Health Passport and
include PMTCT information. Detailed PMTCT documentation in the Passport will support identification of children needing CTX
prophylaxis as well early HIV DNA PCR testing; this will greatly improve the early referral of infected children to care and
treatment.
Namibia's ART program started in 2003 and since its inception, provision of pediatric ART has been an integral component of the
program. To date, 12.6% (7,077/56,054) of all patients on ART are children, ranging from 5% in Erongo Region to 21% in
Oshikoto Region. However, due to the unavailability of pediatricians in most facilities, most pediatric treatment is provided by non-
specialists. ART is currently being provided in 62 facilities; a recent pharmacy survey indicates there could be as many as 101
sites currently providing ART. The complexities of pediatric care, coupled with a lack of confidence among health care workers,
results in pediatric care being rendered disproportionately at higher level facilities. Nawa Life Trust will support communications
interventions to ensure that parents and communities understand how to access available pediatric care and support, and link OI
prophylaxis and treatment services to children.
Namibia developed a pediatric curriculum taught to clinicians who have some experience managing ART patients. This training is
administered through I-TECH and the NHTC; 78 clinicians have been trained. In FY08, I-TECH trained 697 health workers in
delivery of ART services according to national standards; this included a pediatric ART component. However, some sites continue
to reflect low %s of pediatric patients. This is related to the complexity of treating HIV-infected children and points to an area to be
addressed in COP 09. COP 09 will support internships in a pediatric centre of excellence to provide experienced pediatric ART
mentorship to clinical teams and promote stronger understanding of the challenges of providing care and treatment services to
children. APCA will work with ITECH and the MOHSS on the national palliative care training program for in-service training,
training of trainers, and supportive supervision - which includes pediatric palliative care. APCA will also support ongoing review of
training materials and the essential medicines list, to target technical support in policies that increase availability and accessibility
of palliative care medicines for children.
All HIV-positive infants less than 12 months who have had prior maternal or neonatal exposure to an NNRTI-containing regimen
are initiated on d4T/3TC/LPV/r. Infants who have had no prior maternal or neonatal exposure to an NNRTI are initiated on
d4T/3TC/NVP. This decision is in recognition of the reduced efficacy of an NNRTI-based regimen if prescribed too soon after
exposure to an NNRTI used for PMTCT when there are high levels of resistant virus in circulation. As resistance is thought to
wane with time, the recommendations for treating children older than 12 months will be to initiate an NNRTI-based regimen, which
for Namibia is d4T/3TC/NVP. At the inception of the ART roll-out in Namibia, the first line regimen for children was AZT/3TC/NVP.
Children were initiated on ART if they had a CD% of less than 20%, or had WHO clinical stage 3 or 4 disease. At the time, the first
-line regimen was AZT/3TC/NVP. When the guidelines were revised in 2007, this regimen was changed to d4T/3TC/NVP. This
decision was made in light of the two-year donation to Namibia by the Clinton Foundation/UNITAID of d4T-based FDCs. Using
FDCs greatly simplifies medicine administration and eliminates the need to carry excessive volumes of syrups, ultimately
improving adherence. At the time, AZT FDCs were not yet available, and d4T-based FDCs had "first to market" advantage. Since
the revision of the ART guidelines in 2007, AZT-based FDCs have become available, and as d4T is falling out of favor with many
ART providers due to its side effect profile, the MOHSS is considering reverting back to an AZT-based first line regime. Guidance
is waited from the Technical Advisory Committee (TAC) of the MOHSS that advises on changes to clinical practice guidelines as
well as other HIV care and treatment decisions.
The immunological criteria for initiating ART were revised in 2006 for young children less than 18 months who were initiated on
HAART if their CD% was less than 25%. This decision was due to the increased risk of early morbidity and mortality in HIV-
infected infants. In July 2008, Namibia adopted WHO treatment guidelines, mirroring WHO recommendations for initiating ART in
infants and including the policy of initiating HAART in all-HIV infected infants under 12 months, irrespective of their clinical and/or
immunological criteria. Children between 12 and 18 months are started on ART if their CD4% is less than 25%. Children older
than 18 months start on ART if their CD4 is less than 20% or they have WHO stage 3 or 4 disease. WHO's adult criteria of less
than 350 cells/mm3 or WHO clinical stage 3 or 4 disease will apply for all children older than five years. This strategy has been
shown to reduce pediatric HIV-related mortality by as much as 76%.
Namibia started implementing the Integrated Management of Childhood Illnesses (IMCI) strategy in early 2000. Shortly thereafter,
the MOHSS integrated identification of the HIV-infected child into the IMCI algorithms. With Clinton Foundation support to PHC,
the IMCI algorithms were revised in 2007 to include PMTCT, the identification of HIV-exposed children, and the provision of
Pediatric ART. Through training of health care workers (HCWs) in IMCI, more HCWs at lower levels of care will be able to identify
HIV-exposed children and appropriately initiate CTX prophylaxis and HIV DNA PCR testing from as early as 6 weeks of age. The
provision of a complete preventive care package that includes the provision of CTX prophylaxis from the age of 6 weeks has long
been adopted as a standard of care for all HIV-exposed and infected children; the former receive CTX until HIV infection has been
ruled out. Other components of prevention need further strengthening, including malaria prophylaxis and treatment, provision of
impregnated bednets to children under 5, as well as screening and treatment of TB, and the provision of TB Isoniazid Preventive
Therapy (IPT) where active TB disease has been excluded. Organizations such as Pact and Catholic AIDS Action will focus on
incorporating pediatric home based palliative care services into programs. Nutritional assessment and treatment of malnourished
children, as well as the provision of therapeutic and supplementary feeding will be stepped up as malnourished children have poor
treatment outcomes and higher mortality. FANTA-2 will provide support to PEPFAR implementing partners to develop models for
linking pediatric HIV clients to community-based nutrition, food assistance, and livelihood services. The links developed will also
support screening and referral of malnourished or vulnerable pediatric HIV clients and other OVC to facility-based clinical
services.
Similarly, bi-directional linkages will be formalized between the health care facilities and community based organizations looking
after OVCs and those providing home based care. To ensure continuity of care, these young people will need linkages to OVC
service providers on an on-going basis for psychosocial, spiritual, social, and other preventive support. In addition, systems that
link OVCs to the MGECW, MOE, and MOHSS Department of Social Services will be strengthened to ensure that OVCs are
accessing pediatric care and treatment services. The MGECW provides a social welfare grant to those who care for orphaned
children and this will need to be streamlined to ensure that OVC also access care and treatment. Children of adults who are
presenting for pre-HAART and ART registration will also need to be offered testing, as they may also be unknowingly infected.
The referral system will be strengthened by ongoing training and monitoring and evaluation (M&E) efforts, as well as by having
regular coordination meetings between representatives from facility- and community-based service delivery points.
As increasing numbers of HIV-positive children reach adolescence in stable health, issues of disclosure of HIV status and coping
with their awakening sexuality become paramount. Health workers will need to become skilled at communicating with and
counseling HIV-infected children. Child-friendly services will be needed to specifically address adherence and to facilitate open
communication between patients and providers. Abstinence, safer sex practices, reproductive health messaging, and provision of
condoms become important during this challenging time in a young person's life.
TB case finding and provision of TB IPT need to be scaled up for those HIV-infected children in whom active TB disease has been
excluded. Importantly, children of sputum-positive contacts will need to be put on TB IPT after excluding active TB disease. More
details about TB/HIV linkages are highlighted in the TB/HIV narrative. Other aspects of quality care for the HIV-infected child, such
as pain and symptom control, as well as psychosocial and social support, will be provided in a holistic manner. Caregivers of HIV-
infected children suffer tremendous stress and will need to be supported to help ensure adherence to treatment for the HIV-
infected and affected children in their care.
MOHSS embarked on the HIVQUAL quality improvement initiative in 2007. With PEPFAR support, the MOHSS will expand on
the HIVQUAL initiative which began with 16 ART sites in 2007, and was expanded in FY08 to reach all 34 districts of Namibia and
further targeted to at least five health centers offering HIV care through the IMAI strategy. Initially developed for adult care and
treatment, HIVQUAL will expand to include pediatric care and treatment indicators in FY09.
With the roll-out of the electronic patient management system (ePMS) adopted from WHO, data capture, analysis and
transmission from central to peripheral levels will be improved. ePMS has adult and pediatric reporting indicators to meet MOHSS
and OGAC requirements and the system will be central to streamlining and reinforcing HIS data collection efforts and making
better use of ART data for program evaluation. All implementing partners will have regular data quality visits. Targeted M&E
training will support facilities to analyze and use the data locally to inform their program. Bi-directional feedback between national
and regional levels will be supported.
Within the MOHSS, the Response Monitoring and Evaluation (RME) Subdivision is responsible for program data. COP08 and
COP09 funds will support the rollout of data management systems to capture and analyze EID data. RME will measure clinical
outcomes by cohort analysis from data generated by ePMS and EID databases. Lessons learned will be disseminated during
quarterly partners meetings in country and shared in regional and international meetings.
Table 3.3.10:
This activity includes one component: renovation of an ART and antenatal clinics to expand capacity to
care for HIV-impacted clients and to build infrastructure.
Because this activity will impact both adult and pediatric treatment, the funding amount of $86,250
represents 15% of renovation costs; the remaining 85% ($488,750) is reflected in the HTXS program area.
accommodate the large influx of patients, including children, seeking ART. Several MOHSS sites are
providing ART in inappropriate and unsafe environments, such as unused space on tuberculosis wards and
operating theatres. With FY 2009 COP, CDC/Namibia will seek to secure a full-time infection control
technical advisor who will have, among other duties, the responsibility of ensuring that all future renovations
maximize structural interventions that can prevent transmission of TB. Even when not the principal funder
of a renovation or construction project, CDC/Namibia frequently provides equipment, supplies and technical
The USG will continue collaborate with the MOHSS, the Ministry of Works, the Global Fund, and other
ART sites may not always result in more children on ART, but will result in improved quality of services,
Table 3.3.11:
