Detailed Mechanism Funding and Narrative

Years of mechanism: 2008 2009

Details for Mechanism ID: 3078
Country/Region: Namibia
Year: 2009
Main Partner: IntraHealth International, Inc.
Main Partner Program: NA
Organizational Type: NGO
Funding Agency: USAID
Total Funding: $9,989,953

Funding for Biomedical Prevention: Prevention of Mother to Child Transmission (MTCT): $1,763,989

NEW/REPLACEMENT NARRATIVE

The IntraHealth PMTCT activity aims to reach 80% of pregnant women with prophylaxis and reduce new

infant infections by at least 50%. IH currently supports 5 faith-based hospitals (FBH) and 46 health centers

and clinics with a catchment of around 390,000 people in rural and semi-urban settings. The FBH plus 46

associated health centers and clinics have provided PMTCT services for the past 4 years, gradually scaling

up. By end FY09, IH will have supported Catholic Health Services (CHS), Lutheran Medical Services (LMS),

and Anglican Medical Service (AMS) to roll out PMTCT services in a total of 51 service outlets (5 hospitals

& 46 HC and Clinics). IH supports PMTCT programming providing pregnant women with a minimum

PMTCT package integrated into traditional ANC services (syphilis serology, hemoglobin, blood group and

urine test). This package includes for first visit ANC, opt-out CT, rapid testing (RT) with same-day results. It

is estimated that in FY09, 6,450 women will be offered the minimum PMTCT package as first antenatal

clinic (ANC) attendees, and 1,290 will receive ARV prophylaxis at the maternity ward. A minimum of 90%

uptake is expected for both post-test counseling among women attending ANC and for ARVs at delivery for

mother infant pair. Using dual therapy ARV prophylaxis to be introduced gradually in COP08 in replacement

of single dose nevirapine (NVP) as per the updated PMTCT guideline, an estimated 420 new infant

infections will be averted. HIV-positive women identified at first ANC visit are referred to the ART clinic for

initial clinical evaluation, CD4 testing and eligibility assessment for HAART, IPT, or CTX prophylaxis. This

number is currently estimated at around 1,290 women for COP FY 2009. HAART will be offered to those

eligible as per the national guidelines (an estimated 130 women). Those who need it will be enrolled in the

care program that includes regular follow-up counseling, opportunistic infections prophylaxis, STI screening,

TB screening, prophylaxis, and/or referral. PMTCT and ART services are integrated under the same roof in

LMS and 3 of the CHS Hospitals and Odibo HC. In Rehoboth Hospital, referred women go to ART sites

located outside the PMTCT settings that are strongly linked through a referral mechanism involving the

PMTCT district coordinator and the nurse in charge along with the use of the electronic patient management

now in use in the all the ART sites.

Critically, attention will also be directed to strengthening links between PMTCT and standalone VCT sites

for those women who find these sites most convenient. Three of 6 maternity wards have CT services for

women delivering with unknown HIV status. In Odibo, Andara, and Nyangana hospitals, the CT sites are

few meters away from the maternity ward. In collaboration with the MoHSS and the NIP, IH will work with

these facilities to get maternity wards certified as RT sites. Provision of CT services inside the maternity

wards during, and after hours has resulted in tremendous reduction in the number of women delivering with

unknown HIV status (from 25% in 2005 to 13% in 2006). In the future, more women will receive postpartum

CT, closing the gap on missed opportunities. HIV-positive mothers also receive infant feeding and FP

counseling and referral. Currently most sites are counseling and referring HIV positive women fairly well

from ANC through pregnancy and after delivery. However, linkages with commodities supply and follow up

are very weak. IH will work with the MoHSS (PHC) on strengthening this area and improving the recording

system. Additionally for HIV+ mother, support groups will be offered wherever feasible based on the

community dynamics. Mothers-to-Mothers is an example to be explored though use of other less expensive

approaches. In FY09, about 10% of HIV+ women will get nutritional supplementation through leveraging

with other partners such as NRCS. In response to a demonstrated need and as a new part of our PMTCT

program, eligible pregnant and lactating women will be provided with this supplementation in the form of

EPAP. HIV-negative mothers will be offered preventive counseling to maintain their negative status. All

women will be offered couples counseling. The male involvement initiative started in COP FY 2007 will

scale up in COP FY 2009. Currently PMTCT women are counseled and tested with their partners either as

couples or their partner receives CT through referral by PMTCT staff. Within CHS facilities the partner

testing rate has varied between 2 and 2.9% whereas LMS has seen a dramatic improvement to 20% up

from 6.4% of women testing with partners or referring them between COP FY 2007 and COP FY 2008.

Bringing this activity to scale should yield at least 20% testing as couple or referred partners in all sites

while improving also the reporting system. Some men are being tested elsewhere as partners, but their

testing is not linked to their PMTCT referral. Increased number of males will be invited and expected to take

part in the full range of PMTCT activities. Messages will also address gender-based violence, stigma, and

discrimination especially related to disclosure and partner testing. To enhance a family-focused care

approach, the partner and other family members such as children from previous pregnancies will be invited

to access HIV testing and care and treatment services. Through couples counseling, discordant couples will

be closely followed-up with condom promotion, and offered prevention with positives as per the current

initiative. For HIV - women at first ANC, a retest will be offered to those tested 3 months earlier alternatively

at/or after delivery. This new approach in the revised guideline will be reinforced through training and

ongoing clinical mentoring. Current guidelines recommend exclusive breast feeding for all infants for the first

6 months of life. For HIV-exposed infants replacement feeding is recommended under AFASS conditions.

At 6 months, abrupt cessation of breast feeding, and introduction of unmodified animals milk and

complementary foods are recommended. Most mothers in FBH (>90%) opt for exclusive breast feeding as

AFASS criteria are not met. To enhance feeding counseling program and nutritional assessment, IH will

continue staff training and support to the kitchen corners initiatives started in COP FY 2007. Accordingly,

postnatal services for HIV-exposed children will continuously be strengthened through direct referral to child

health services (infant immunization, growth monitoring, and nutritional assessment) which are part of the

district primary health care activities. All HIV-exposed infants are enrolled for follow up, and at 6 weeks, they

are offered CTX prophylaxis and diagnostic PCR testing. PCR is available in all IH supported faith based

facilities and in an increasing number of satellite health centers and clinics and it is performed in

accordance with the national algorithm. During this follow up, micronutrient supplementation and TB

screening for all infants as well as Isoniazid prophylaxis for eligible babies and CTX will be provided. Early

infant diagnosis allows timely clinical evaluation, entry to care, and initiation of HAART for young infants.

With the new WHO recommendation adopted nationally, every HIV positive infant less than 12 month of age

will start HAART regardless of his/her immunological status. This recommendation is likely to improve entry

to care and treatment of many infants who would otherwise have progressed to disease and death rapidly.

Implementation of early infant testing, diagnosis, and follow up is critical to provide early initiation of life-

saving antiretroviral therapy for all HIV-infected infants in the first year of life. As well, urgent provider-

initiated testing and counseling is strengthened as a routine part of care for any infant or child presenting to

health facilities with signs, symptoms or medical conditions that could indicate HIV infection. More PMTCT

Activity Narrative: staff will be trained on the dried blood spot technique (DBS) in collaboration with NIP, and also on post-DBS

counseling. Because a significant number of children are lost to follow up, more efforts in tracing for

defaulters with help of support groups, community volunteers and other mechanisms will be enhanced.

During COP FY 2009, 965 infants born in the 5 FBH are expected to be tested for DNA-PCR (~75% of

infants born to HIV-positive mothers). Documented HIV+ as well as HIV- infants who are still breast-fed

(until 2-3 months after complete cessation of breast feeding) will be followed up using HIV exposed infants

registers. Orphan infants and children registered in care will be referred to the available OVC care in the

area.

M&E: IH will ensure quality of all components of the program through supportive supervision, clinical

mentoring, familiarization of staff on the data collection tools, scrutiny of reports generated and feedback to

centers. These reports provide data elements, and indicators to track the program performance. The

support supervision visits will include facility check list, data quality assessment, analysis of exit interviews

and quality assessment of counseling (infant feeding & family planning), and success of referrals. As part of

the technical assistance services to the MoHSS, the IH team will continue to be involved in the regular

update of the PMTCT guidelines with the aim to use more effective ARV prophylactic interventions as per

WHO recommendations for maximum reduction of MTCT. Results of an evaluation of PMTCT effectiveness

conducted during COP FY 2008 will be used for program improvement. IH in collaboration with MoHSS,

HIVCS & I-TECH, will support training/retraining of 60 HCW (public & private sector) in the updated

guidelines. In order to engage the community, increase participation and improve services utilization, all IH

partners will continue community awareness, mobilization, and education with regard to creating demand

for the available PMTCT services in different facilities.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16129

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16129 4734.08 U.S. Agency for IntraHealth 7361 3078.08 The Capacity $1,719,138

International International, Inc Project

Development

7403 4734.07 U.S. Agency for IntraHealth 4406 3078.07 The Capacity $1,379,656

International International, Inc Project

Development

4734 4734.06 U.S. Agency for IntraHealth 3078 3078.06 The Capacity $963,970

International International, Inc Project

Development

Emphasis Areas

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

* Increasing women's access to income and productive resources

* Increasing women's legal rights

* Reducing violence and coercion

Health-related Wraparound Programs

* Child Survival Activities

* Family Planning

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $141,115

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Estimated amount of funding that is planned for Food and Nutrition: Commodities $40,000

Economic Strengthening

Education

Water

Program Budget Code: 02 - HVAB Sexual Prevention: AB

Total Planned Funding for Program Budget Code: $9,275,576

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

PEPFAR/Namibia's prevention portfolio supports the Government of the Republic of Namibia's (GRN) Medium Term Plan (MTPIII)

and National Strategic Plan on HIV/AIDS (2004-2009). All prevention initiatives are integrated within PEPFAR-supported services

to orphans and vulnerable children (OVC), systems strengthening, care, and treatment initiatives, and are coordinated with the

GRN and other donors including the Global Fund and the UN Team. Building and strengthening these linkages will help ensure a

national response that is sustainable by increasing capacity among Namibian institutions.

There are many gaps in understanding Namibia's HIV epidemic, including epidemic drivers at regional and lower levels. During

the COP08 national planning retreat, US Government (USG) officials presented a preliminary analysis of national epidemic drivers

based on existing data sets, which include ANC surveillance, 2006 Demographic and Health Survey (DHS), and voluntary

counseling and testing (VCT) client intake data. National ANC prevalence is 19.9%, with wide variation from 7.9% in the east and

northwest desert areas, to 39.4% in Katima Mulilo, an area that intersects with a major transportation corridor between Namibia,

Botswana, Zambia, and Zimbabwe. Over time, the average ANC rate has stabilized, suggesting minimal declines in incidence,

despite data that suggest increasing adoption of abstinence and condom use by youth. Men are more likely to have two or more

partners, with the number of partners increasing with increased alcohol use. Marriage rates are decreasing. Women are infected

more often and at younger ages than men. Limited data are available that identify geographic hotspots and high risk populations

within the more generalized epidemic.

Currently, the GRN is reassessing its national response to prevention, with vigorous support from the USG and other donors. With

support from PEPFAR, the GRN conducted a national prevention assessment and the first ever National HIV Prevention

Consultation in November 2008 which included an analysis of existing data sets to further understand epidemic drivers, a national

inventory of existing multisectoral prevention programs, and a national mapping of resources which will become the basis for

referral systems within defined geographic areas. This assessment will drive the creation of a national prevention strategy and a

prevention technical working group. The prevention assessment will help the GRN create a prevention portfolio based on

epidemiologically sound priorities and evidence-based approaches.

With COP 08 funding, the USG supported the placement of a Prevention Coordinator within the Ministry of Health and Social

Services (MOHSS), thus ensuring multi-sectoral support for prevention within the GRN. The coordinator will provide focus and

coordination in prevention efforts. The GRN's leadership in the national prevention assessment and the hiring of a National

Prevention Coordinator are major achievements to strengthen prevention in Namibia.

While Namibia has a generalized HIV epidemic, data analyses strongly suggest that there are geographic areas with concentrated

epidemics and most at-risk populations (MARP) with risk behaviors higher than that of the general population. The USG will

encourage GRN efforts to ensure that targeted populations have access to at least a minimum prevention service package, which

includes behavior change communication (BCC) integrated into structural responses (workplace, schools, community groups,

FBOs) and outreach to youth, supported by mass media campaigns, counseling and testing (CT), condom distribution, STI

screening and treatment, male circumcision, prevention with persons living with HIV/AIDS (PwP), prevention of medical

transmission services, post-exposure prophylaxis (PEP), prevention of mother-to-child transmission (PMTCT), and supportive

policies and advocacy.

Targeted messages will focus on what are known to be the main epidemic drivers in Namibia: multiple concurrent partnerships

including trans-generational and informal sexual relationships, and social norms that facilitate HIV transmission including male

norms and alcohol abuse. Target audiences will vary depending on the implementing partner's prevention focus, the site of

intervention, and the group at risk.

In targeting Namibia's highest prevalence geographic areas and MARPs, the minimum prevention service package will include

BCC focused on outreach services to MARPs, CT, targeted media, condom distribution, STI services, and prevention, care and

treatment referrals. High prevalence areas include the northern regions of Namibia where at least 45% of the population resides,

areas with high migrant populations (e.g. mining, tourist and agricultural areas), and transit corridors. MARPs include the military,

prisoners and police, as well as people engaged in transactional sex.

AB-funded interventions targeting youth include the integration of age-appropriate HIV/AIDS learning activities into primary and

secondary curricula and peer education activities targeted to in-and out-of-school youth that emphasize abstinence and fidelity

messages, personal risk assessment, and negotiation skills. The USG will continue to support community action activities which

target a broad range of community members with AB messages, as well as the micro-credit program targeted to young women

ages 15-30 who are at risk of engaging in cross-generational and informal sexual relationships. Other AB-funded PEPFAR

programs include the national scale up of the Ministry of Education's (MOE) workplace program, which includes referrals to

prevention, care and treatment services as well as teacher training to ensure high quality HIV/AIDS curricula implementation.

Uniformed services - the military and police - will continue to receive technical assistance to integrate abstinence/be faithful (AB)

programs into their existing infrastructure. The MOHSS community counselors (CCs) will continue to provide AB-focused

messages to the clientele of public and faith-based hospitals. The USG will continue to support the Ministry of Information

Communication and Technology (MICT)'s national Take Control mass media relationships campaign, which targets B-focused

messages to Namibian men of reproductive age.

Other sexual prevention (OP) funded activities include ongoing targeted BCC, condom distribution, and STI and CT referrals to

migrant populations and those working and living along transit corridors. The USG, in collaboration with the GRN and other

development partners, works with the uniformed services to provide technical assistance to integrate OP programs into their

existing infrastructure. The USG will continue to support community-based organizations that target a broad range of the

population with AB/OP messages and referrals to CT, care and treatment services. The GRN-supported CCs will continue to

deliver AB/OP-focused messages to clientele of public and faith-based hospitals.

The USG will ensure that, as appropriate, activities targeting MARPS will reinforce the MICT's national Take Control mass media

relationships and alcohol campaigns. USG will continue to support the MOHSS' socially marketed "Smile" male condom as well as

the Femidom female condom through commodity purchasing and widespread distribution throughout PEPFAR-supported

prevention, care and treatment programs, including PwP. The USG will support the launch of mobile services during COP 09,

which will include HIV testing, as well as prevention, care, and treatment services to underserved populations and MARPS.

With the support of PEPFAR, the MOHSS continues to provide opportunities for leaders to come together to address HIV and

AIDS. In February 2008, the President of Namibia participated in the first ever National Male HIV Conference on HIV/AIDS, which

had as its theme, "Namibian Men and HIV/AIDS, Our Time to Act." In May 2008, the First Lady of Namibia presided over the first

National Female Conference on HIV. These two conferences identified many important gaps that need to be addressed through

further research, strategic planning and implementation, and innovative and effective prevention programming. Many leaders

attending the conferences were motivated to participate in the May 9th National HIV Testing Day. In 2009, the MOHSS will

replicate the National Male and Female Conferences on HIV/AIDS as well as the rollout of similar conferences at the regional

level. The replication of the national conferences will help measure progress in achieving stated commitments and outline further

action items.

Alcohol abuse is prevalent throughout Namibia, and contributes to risky behaviors and lack of treatment adherence. Other

prevalent male norms and behavior, including sexual violence, undermine prevention efforts. The USG will continue to support

mainstreaming of alcohol and gender messaging into all programming within clinical and community settings and in mass media.

The gender program supports OGAC's global gender initiative, adapting the evidence-based "Men as Partners" approach to

Namibia.

With support from the PEPFAR Alcohol and HIV Initiative, alcohol mainstreaming efforts will mirror the gender approach of making

technical resources available to all PEPFAR-supported partners, including the MOHSS' Coalition for Responsible Drinking

(CORD) to ensure sustainable in-country capacity building. Other potential partners in this effort will include the Shebeen Owners

Association and the Namibia Breweries. The USG will pilot a number of innovative alcohol and HIV programs in Namibia,

including brief motivational interviewing and screening at facilities, point of sale or consumption education outreach, and

expansion of the Alcoholics Anonymous network. The USG will also support the development of alcohol and addiction certification

training within the University of Namibia (UNAM).

The USG will strengthen the integration of bi-directional referral systems. Approaches include expansion of access to HIV testing,

strengthening prevention services (e.g. PMTCT, risk reduction counseling, PwP, CT, condoms, STI screening, family planning

referrals) in health care settings, strengthening prevention messages for HIV-negative people within service settings, and a

national strengthening of STI services including suppressive therapy for herpes simplex virus.

PEPFAR will support 35 facility-based case managers and 15 regional supervisors, trained in performance improvement

methodologies, who will play a key role in ensuring active bi-directional referrals within the prevention, care and treatment

continuum. In addition, partners who receive AB and/or OP funding will continue to work with the USG to implement practical and

age-appropriate referrals to facility and community services. These referrals may also be for services that the partners do not

provide themselves, such as voluntary family planning services. .

The case management program is distinct yet complementary to the Community Counselor Initiative in that it is comprised of a

higher-level cadre of professionals trained in psychology or social work. Some of the primary responsibilities of the case

managers include defaulter tracing, facilitation of support groups, and making bi-directional referrals between facility- and

community-based services. Case managers will be expected to be repositories for information about HIV and HIV-related

services in the communities in which they serve, including psychosocial support such as domestic violence, drug/alcohol

counseling, and mental health services. In addition, the case managers will support the services provided by the community

counselors in care and treatment settings, and will support and assist with referrals from the prevention with positives (PWP)

program activities. The case managers will encourage linkages between community and facility-based PWP activities.

The USG will also support taking OGAC's facility-based Prevention with Persons Living with HIV/AIDS (PwP) Initiative to national

scale, ensuring that all HIV positive individuals, their partners and families have access to high quality clinical and community

services, guided by case managers. The prevention interventions include provider- and counselor-delivered prevention messages,

family planning counseling and services to HIV positive women and their partners, STI services, and testing of partners and

children. HCWs will deliver targeted behavioral messages to patients on disclosure, partner testing, and sexual risk reduction

during all routine clinic visits. In addition, Namibia will also expand community PwP activities. A PLWHA-driven social marketing

campaign will increase demand for services as well as reinforce healthy living behaviors.

The prevention program will continue to focus on strengthening technical and programmatic quality. Incidence measurement and

the AIDS Indicator Survey will greatly strengthen Namibia's understanding of epidemic drivers and the impact of USG-supported

programs, and possibly re-direct the GRN's and USG's strategic prevention design. The technical quality of BCC requires

strengthening, and the USG will continue to support technical assistance to implementing partners in BCC through a new activity

with C-Change. The USG will conduct a review of each BCC program to strengthen quality assurance and impact. All prevention

partners will receive technical capacity building inputs in order to strengthen the overall quality of BCC programming within service

delivery, mass media communications, interpersonal communication, and effectively mainstream gender and alcohol issues into

ongoing programming.

Throughout the year, the USG/Namibia's Prevention Interagency Technical Team (ITT) will continue to guide USG support for

prevention activities closely, thus ensuring ongoing coordination between agencies and implementing partners. To ensure buy-in

and coordination on a broader scale, the ITT in turn will coordinate efforts with the Prevention Technical Advisory Committee

(TAC) comprised of the MOHSS, the donor community, PLWHAs, and key stakeholders.

Table 3.3.02:

Funding for Sexual Prevention: Abstinence/Be Faithful (HVAB): $315,359

NEW/REPLACEMENT NARRATIVE

It is estimated that 24 to 44 new HIV infections take place every day in Namibia (UNAIDS, 2007), most of

which occur through heterosexual activities and are driven by multiple concurrent partnerships (MCP) and

alcohol abuse. IntraHealth (IH), with its implementing partners, is supporting every effort to curb this trend

and aims to meet the incidence reduction goal as set out in the Medium Term Plan for AIDS Prevention and

Control (MTP III). The call for accelerated and intensified prevention programs acknowledges that there is

no meaningful and successful treatment program unless prevention efforts are brought to scale. The current

estimated global trend (UNAIDS, 2007) suggests that for every individual initiated on treatment in 2006, 6

new infections were registered. This vicious cycle needs to be broken.

According to the 2000 and 2006 Demographic and Health Survey (DHS) the median age of sexual debut in

Namibia has remained around 18 years for both boys and girls. The Lifeline-Childline (LL/CL) school

program, supported by PEPFAR since FY 2004, offers a unique opportunity to reach pre-primary, primary

and high school children with the most age-appropriate messages on AB and life skill-based sexual

communication and HIV/AIDS education programs. This is in line with the MTP III goal of reaching 100% of

children with behavior change communication in primary schools and behavior intervention in secondary

schools and is undertaken recognizing the synergistic efforts of other partners' programs such as Ministry of

Education (My Future is My Choice, Windows of Hope) and Catholic Aids Action youth education programs

(Stepping Stones, Adventure Unlimited).

In FY 2009 COP, LL/CL will continue to target school going children aged 7-18 years to address attitudes

and behavioral issues related to abstinence, fidelity, violence, sexual predation, alcohol abuse,

intergenerational sex, as appropriate to the school grade and age. LL/CL programs put an emphasis on

intergenerational sex as it has been identified as one of the main drivers of the Namibian epidemic and to

which young girls are particularly susceptible and vulnerable. Sexual predators offer money and materials

that these young girls, especially those living in communities below the poverty line, cannot obtain at home.

Targeted interventions for girls will be put in place to address issues of violence and coercion against girls

with the aim of reducing gender based violence (GBV). LL/CL employs a number of interactive age

appropriate communication techniques. The messages include topics such as sexual rights, reproductive

health rights, gender and power, gender roles and substance abuse. The following are the techniques

employed by LL/CL on addressing age specific needs of the children using the above mentioned topics:

grades one and two, LL/CL uses puppetry, for grades five to seven, the interactive curricula "Feeling Yes,

Feeling No;" and for grades nine to twelve (older children and adolescent), the program termed "Being a

Teenager." The "Feeling Yes, Feeling No" program has specific topics for each age group: 3-8 years with

puppetry on topics such as "My Body," "How to Say No," and "Private Parts for Girls and Boys;" drama for

ages 8-9 years with topics on identifying feelings, domestic violence, sexual assaults by a trusted person,

caregiver, friends, family member or teacher; ages 9-10 years with drama on topics on the above mentioned

subjects and HIV, stigma and discrimination; ages 10-13 years drama topics on all of the above as well as

how to get infected, teenage pregnancies and alcohol abuse. "Being a Teenager" targets 13-17 years and

discusses topics on feelings, domestic violence, sexual debut, alcohol abuse, cross-generational sex and

risky behaviours and their consequences.

This package of programs targets approximately 6% of total learners' population in each age group across

all 13 regions in Namibia. The approaches provide youth with a good foundation for decision making,

building refusal and negotiation skills, empowerment through accurate information on rights and sources of

assistance. Under FY COP 08, LL/CL will collaborate with AED and UNICEF in the after school programs

through referrals for follow-ups and joint programs. Additionally, LL/CL makes use of national events such

as the 16 days of activism against GBV by collaborating with other partners such as Ministry of Gender,

Women Solidarity and Women Action for Development and Sister Namibia. This platform provides an

opportunity for specific messages for women and girls, advocating for rights for women and children and

prevention of GBV.

During FY 2009 COP, LL/CL support teams will continue to visits schools, spending more in-depth time at

each school, though this will mean fewer learners covered. The extra time will increase the message dosing

and give real opportunities for learners to grow in their understanding and capability for making responsible

decisions and for identification of issues and for referrals. These referrals, tailored to the age and needs of

each child, will be not only for typical welfare services but also include OVC care (linked to each school),

and as appropriate, STI screening for those sexually abused, CT with parental consent for those less than

16 years of age, and referrals to care as needed. Many teachers are unprepared and lack confidence to

support A&B activities. Thus, in the afternoons facilitators will continue to hold workshops with teachers but

add duty bearers, hostel wardens, parents, caregivers etc. They will receive training on child abuse, rights

and protection, together with tools on how to identify children needing help and referrals. Teachers' skills

are developed to facilitate dialogue with abused children and provide role models for children. Since

program inception, this approach has resulted in a significant increase in the number of abuse cases

reported and referred for counseling.

After the LL/CL team has received training in age-relevant gender messages from the Men and HIV

curriculum (EngenderHealth), pre-school girls and boys and older ones will be given opportunities to

recognize unhelpful and risk-related gender norms and be given tools to challenge these. These norms

include risk of alcohol and substance abuse and will be integrated into all aspects of the program. In order

to reduce GBV and increase knowledge on women's legal rights, special emphasis will be placed on girls

during the after school programs to sensitize and create awareness on GBV and the rights of girls for safety

and protection. Information on when and where to seek help will be emphasized.

With TA from its dedicated Prevention Advisor and C-change, LL/CL programming will also receive capacity

building support in behavior change communications (BCC). A baseline assessment of the BCC quality was

conducted in FY 2008 COP and will provide basis for further evaluation.

LL/CL, with support from PEPFAR and UNICEF, will maintain its national (all 13 regions) Uitani Child Line

Activity Narrative: radio program by and for children. This is the only known children radio in the country and enjoys the

support of the community. LL/CL estimates that the show reaches more than 100,000 members of the

public, essentially children. A number of programs have been translated into Oshiwambo and broadcast on

the Oshiwambo radio service. During FY 2009 COP, this programming will continue to grow and additional

languages will be introduced expanding the radio services to 6 languages if assistance available. Uitani

Child Line radio has been operating since 2004, and is a highly regarded program that employs child

participation. 35 children aged 8-14 plan and record 52 programs per year, which are broadcast weekly on

three stations (NBC, Katutura community radio, Oshiwambo radio), A radio drama, written and produced by

students of the Media Department of the College of the Arts as part of their curriculum, is also broadcast

weekly. The program content echoes and reinforces themes covered in the schools which include critical life

skills messages around decision making, abstinence and being faithful, and access to trained counselors. In

order to build the capacity of child presenters and producers, skills building sessions are held 8 times per

year in areas of broadcasting training, personal growth and peer counseling. During FY 2008 COP, LL/CL

will continue to offer gender training using messages from the Men and HIV curriculum and will strengthen

topics such as risk-related gender and social norms, alcohol and male circumcision mainstreaming as it

relates to the broader set of prevention interventions. The program will further be strengthened in FY 2009

COP to specifically target young girls with targeted BCC messages relevant to girls of different age groups.

A needs assessment will be conducted with support from the IH Prevention Advisor and C-Change to

identify age specific needs of girls, develop specific BCC messages, conduct a trial and adapt accordingly

for programming. To ensure quality and performance improvement, BCC integration with TA from the IH

Prevention Advisor (PA) and support from C-Change will contribute to an effective supportive supervision of

the program through regular visits, mentoring and routine analysis of data and use of check list. The project

will sharpen youth messages around delay of sexual debut, transactional and intergenerational sex, and

alcohol abuse among other prevention messages and distribute doses of messages during FY09. The PA

will liaise with C-Change, and Regional AIDS Committee Education to identify additional school districts

underserved in terms of HIV prevention messages and/or schools with high pregnancy rates. Monitoring of

teachers reports, reported abuse cases or referrals for counseling and overall youth sexual behavior

including teenage pregnancies in schools covered by LL/CL could provide a gauge of program

effectiveness.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16130

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16130 6609.08 U.S. Agency for IntraHealth 7361 3078.08 The Capacity $379,951

International International, Inc Project

Development

7408 6609.07 U.S. Agency for IntraHealth 4406 3078.07 The Capacity $397,894

International International, Inc Project

Development

6609 6609.06 U.S. Agency for IntraHealth 3078 3078.06 The Capacity $219,795

International International, Inc Project

Development

Emphasis Areas

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

* Increasing women's legal rights

* Reducing violence and coercion

Health-related Wraparound Programs

* Child Survival Activities

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $25,228

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.02:

Funding for Sexual Prevention: Other Sexual Prevention (HVOP): $549,121

NEW/REPLACEMENT NARRATIVE

An estimated 24 to 44 new HIV infections take place every day in Namibia (UNAIDS, 2007). Most of these

new infections occur through heterosexual activities and driven by multiple concurrent partnership (MCP),

trans-generational sex and alcohol abuse. IntraHealth/Namibia through the Capacity Project (CP), with its

implementing partners, is supporting every effort to curb this trend and aims to meet the incidence reduction

MTP III goal. The call for accelerated and intensified prevention programs acknowledges that there is no

meaningful and successful treatment program unless prevention efforts are brought to scale. The current

estimated global trend (UNAIDS, 2007) suggests that for every individual initiated on treatment in 2006, 6

new infections were registered. This vicious circle needs to be broken.

Targeting the general population, the sexually active adult population, the youths aged 15 to 24 years and

the MARPs living within health facility catchments areas including surroundings towns and communal areas

of each CP supported prevention partner. An estimated 24,000 people (females and males) will be reached

through outreach prevention activities during COP09.

These activities comprise a wide range of Behavior Change Communication (BCC) activities and prevention

interventions that will expand condoms promotion and distribution, post exposure prophylaxis (PEP),

community outreach and mobilization with prevention messages around the ABC approach and prevention

with positives initiative. The MC incorporated in the menu of prevention services will be scaled out.

To ensure increased knowledge and skills to promote HIV/AIDS prevention through BCC, CP will maximize

the use of the prevention focal person and collaborate with C-Change, LL/CL to continue to train volunteers,

peer educators, counselors, community mobilizers, community activators using a comprehensive skill

building approach that include personal growth, basic prevention counseling, HIV/AIDS competency skills

as defined in the approved curriculum (about 200 during FY10). Community awareness and mobilization will

focus on addressing prevention messages to the community and MARPs. LL/CL will continue to use the

opportunity of the Oshikango border town to address the special needs of migrant population, truck drivers

and commercial sex workers

The operational teams (district coordinators and volunteers) will deliver messages through different

platforms that include one-on one education or prevention counseling, schools within 50 km radius,

teachers, women and men groups, church groups, community and traditional leaders, social events

partnering with Nawa Soccer, support groups. A full range of integrated prevention activities will be

available at each site and when not, clear referral linkages for clients will be established. CP along with

other PEPFAR partners will ensure appropriate combination of dose (intensity) and quality needed to affect

sustainable community change.

Social capital building is already happening using stakeholder meetings in each district where FBO staff,

RACOC, CACOC, traditional leaders and healers, community and other FBO/CBO organizations, PLWHA

and volunteers are meeting on quarterly basis. CP will continue supporting this platform to ensure critical

issues such as male norms relating to the HIV/AIDS prevention and Male Circumcision (MC) are addressed.

Issues of stigma and discrimination, violence and coercion against women will also be addressed.

To reduce women vulnerability to the epidemic, increasing efforts will be made to give them access to the

currently available support group IGA (Andara, Nyangana and Oshikuku) whereby they currently constitutes

75% of the support group membership. CP will support Onandjokwe, Odibo and Rehoboth to set up or

resuscitate or alternatively strengthen similar activities.

To ensure continuous attention and improvement in male norms initiative and behavior impact, CP will

continue to liaise with expertise within EndengerHealth and other USG partners. LL/CL training curriculum

will continue to include cultural and social male norms and behavior supplying domestic and sexual

violence. The training will ensure that all trained counselors are familiar with how to motivate men for social

change and gender transformation and obtain their participation in this very ambitious journey. These

activities will be linked to the male mobilization and involvement program taking place within the C&T

centers and within community within the catchment population of FBOs districts. At service delivery points,

CP and partners will strengthen the model of invitation cards for male partners for couple counseling and

increased male responsibility in PMTCT. This model started in COP FY 2007, was scaled up in COP FY

2008 and will be continued in COP FY 2010. Currently around 2% of PMTCT women are counseled with

their partners within CHS facilities whereas LMS site has seen a dramatic improvement with up to 20% of

women testing with partners or referring them. Bringing this activity to scale should yield at least 20%

testing as couple or referred partners in all sites while improving also the reporting system.

Integration of prevention programming into care and treatment has become imperative in CP supported

sites. The growing number of PLWHA calls for specially targeted prevention programs to ensure they don't

become a pool of HIV transmitters. These interventions i.e. consistent and correct condom use especially

for discordant couples, partner reduction, C&T for the family, PMTCT, family planning, STI screening and

treatment for PLWHA will be enhanced. Namibia is one of the three PEPFAR focus countries chosen to

implement the PwPLWHA model. Following a successful piloting in FY07 and FY08 through USG partners,

CP will continue to scale up this initiative in all facilities.

To mitigate the impact of HIV/AIDS on FBH employees, workplace programs will be strengthened to

address the needs of support staff and their families with regards to HIV/AIDS information, peer education,

prevention and care initiatives, stigma and discrimination reduction, confidentiality issues as well as overall

reinforcement of infection control policy within the hospital settings.

The misuse of alcohol has a widespread negative impact on public health in Namibia. One local study

conducted in 2005 by the Ministry of Health and Social Services (MOHSS) and the Khomas Region Police

indicated that 56% of adult Namibians in Khomas use alcohol, 30% abuse alcohol over weekends, 20-25%

of road accidents involve intoxicated people, and on-the-job fatalities linked to drugs and alcohol account for

15%-30% of all accidents. According to the same study, accessibility to alcohol is high - there are more

Activity Narrative: liquor outlets compared to other types of businesses in most towns, and "shebeens" (informal drinking bars)

supply alcohol to customers on a 24 hour basis, as well as illegally to minors. A KAP study of some

communities in Namibia found being drunk was positively associated with having multiple partners (NLT,

2006). In a recent longitudinal population study in Rakai, Uganda alcohol use was shown to be associated

with a relative risk of 1.67 for men and 1.40 for women for HIV acquisition. A recent study conducted by the

University of Boston found that heavy consumption of alcohol speeds up the onset of AIDS in those infected

by HIV. CHS conducted a study in 2005 which indicated that 41% of patients who defaulted ARVs at St.

Mary's Hospital in Rehoboth did so on account alcohol.

In 2009, Namibia will take part of an OGAC special initiative to address the interface between alcohol and

HIV. In anticipation of Namibia's participation in this special initiative, alcohol experts from CDC and

USAID (i.e., "the interagency alcohol team") came to Namibia in July 2008 to conduct an extensive

assessment of the HIV and alcohol situation in Namibia. The interagency alcohol team, in collaboration with

Namibian counterparts, recommended several activities that Namibia should undertake to address alcohol

and HIV. The recommendation of activities include:

1. Expanding alcohol and HIV National Campaign;

2. Create a point-of-sale-intervention for Shebeen owners;

3. Increase the pool of professionals with expertise in alcohol abuse;

4. Implement and evaluate an intervention for alcohol related individual risk behaviors in VCT and

community settings;

5. Expand implementation of Brief Motivational Interviewing (BMI) for alcohol reduction in health care

settings;

6. Expand AA support groups in the community and in prisons;

7. Advocate for legislation and operationalization of national alcohol policy;

8. Advocate on enforcement of existing regulations; and,

9. Expand the Coalition on Responsible Drinking (CORD) to cover all regions.

In order to implement these recommendations, COP 2008 and 2009 alcohol-related funds will be used to

complement the special initiative funds. In COP 2008, it was anticipated that IntraHealth (IH) would use

alcohol funding to create an outpatient treatment model. However, based on recommendations from the

interagency alcohol team, it was recommended not to pursue an outpatient treatment activity based on

guidance from international alcohol experts. As such, the proposed COP 08 activities have been

reprioritized. IH will specifically use COP 08 and COP 09 dedicated alcohol funding to participate in the

evaluation of an intervention for alcohol related individual risk behaviors in VCT settings. In addition IH will

continue to support the social worker it seconded to Etengameno, the MOHSS national alcohol addiction

treatment center.

Other potential activities IH will be involved in depending on availability of funds includes: engaging

population opinion leaders (POL) through a methodology developed and tested by the Academy for

Educational Development and support the National Shebeen Association to implement a point-of-sale

intervention.

In COP 07 and COP 08, IH initiated the BMI alcohol reduction approach in the faith-based health care and

VCT settings. BMI includes brief alcohol screening and counseling techniques and referral for rehabilitation

as required. BMI is used in outreach and primary care settings to change at-risk alcohol use patterns.

Properly integrated into existing programs, the technique enhances current HIV prevention efforts and

promotes treatment compliance to HIV medications. In COP 09, the IH will scale up the use of BMI for

alcohol reduction within clinical settings and HIV counseling rooms using other prevention funding. In

addition, with resources from the alcohol special initiative, MOHSS will expand this approach to the public

health sector.

All alcohol activities implemented by IH will be done in close collaboration and guidance with the alcohol

technical workgroup in order to contribute to achieving the objectives recommended by the inter-agency

workgroup on alcohol.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16131

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16131 7459.08 U.S. Agency for IntraHealth 7361 3078.08 The Capacity $282,500

International International, Inc Project

Development

7459 7459.07 U.S. Agency for IntraHealth 4406 3078.07 The Capacity $20,000

International International, Inc Project

Development

Emphasis Areas

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

* Increasing women's access to income and productive resources

* Increasing women's legal rights

* Reducing violence and coercion

Health-related Wraparound Programs

* Child Survival Activities

* Family Planning

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $114,500

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 04 - HMBL Biomedical Prevention: Blood Safety

Total Planned Funding for Program Budget Code: $2,000,000

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

PEPFAR-Namibia's biomedical prevention activities include male circumcision, blood safety, and injection safety. PEPFAR does

not currently support injecting or non injecting drug user activities in Namibia.

Male Circumcision

According to recent research, male circumcision can considerably reduce the risk of HIV transmission from infected women to

men. Three randomised clinical trials in South Africa, Uganda and Kenya, were conducted to establish whether male circumcision

would lead to a decrease in HIV transmission. These studies found that circumcised men were significantly less likely to become

infected with HIV in comparison to uncircumcised men. As a result of these findings, in March 2007 the World Health Organization

(WHO) and the United Nations Programme on HIV/AIDS (UNAIDS) officially recognized male circumcision as a strategy for

preventing the transmission of HIV from women to men.

These developments have been of great interest to Namibia, where the HIV prevalence among pregnant women is estimated at

19.9%, among the highest in the world, and only 21% of men are circumcised. In its Medium Term Plan III for HIV/AIDS in

Namibia, the Government acknowledges that HIV prevention is critical to the national response to HIV and AIDS; however, the

current response is not making a significant impact on new infections. A stronger response is needed. The Ministry of Health

and Social Services (MoHSS) is committed to including male circumcision as an additional HIV prevention intervention.

In 2008, PEPFAR and UNAIDS, in collaboration with MOHSS, supported a situation assessment to provide information on the

acceptability of scaling-up male circumcision (MC) services as an HIV prevention strategy in Namibia. The approach was an

adaptation of the WHO Male Circumcision Situation Analysis Toolkit. This was an essential first element which allowed Namibia

to determine the current status of male circumcision activities and map the way forward regarding male circumcision as an HIV

prevention strategy. The assessment consisted of four components:

1. A desk review of existing literature and research on male circumcision as well as mapping existing services in Namibia;

2. A qualitative study to look at perceptions and attitudes of people toward circumcision;

3. A facility readiness survey to describe the requirements for scaling up services in terms of infrastructure and human resources;

and,

4. A cost analysis to understand the financial implications of scaling up male circumcision services.

A stakeholders' meeting was held in August 2008 to share the results of the situational assessment, which informed the

development of a draft male circumcision policy and action plan. It is expected that the male circumcision policy and action plan

will be approved by MOHSS and Parliament in early 2009.

The MOHSS recognizes that the initiative will require very careful and sensitive planning, and further recognizes that MC should

be implemented not as a standalone intervention but rather as part of a national comprehensive prevention package.

Based on initial drafts of the MC policy and action plan, the following activities have been proposed for PEPFAR funding: (1)

training of MC service providers in the public and faith-based sectors; (2) development of an information, education, and

communication (IEC) strategy and intervention to address acceptability issues and create demand; (3) MC-related commodity

procurement; and (4) hiring of additional health care providers to perform MC based on anticipated needs in the public and faith-

based sectors

In early 2007, the MOHSS created an MC task force with the responsibility to create a national MC strategy with supporting

policies and technical recommendations. Task force members represent MOHSS, USG, UNAIDS, WHO, the Global Fund, and

key members of the NGO community including University Research Company, IntraHealth and Nawa Life Trust (which are also

USG-supported partners). The Namibia Male Circumcision Task Force was responsible for coordinating and overseeing the

situation assessment, and will continue to support the finalization of the male circumcision policy and action plan.

Strategic information (SI) on MC will be essential to guide and monitor scaling-up of the service. SI will support the development

and dissemination of best practices as well as provide essential information for program implementers and policy makers. As the

service is rolled out and promoted in country, service provision indicators will need to be incorporated into the routine monitoring

and evaluation process. Specific process evaluation activities will also be carried out to guide design of service provider training

curricula, to optimize IEC campaigns that can create demand for MC in the general population, and to create commitment among

service providers.

These MC activities will have national coverage as they will both facilitate national policy development and guidelines, as well as

support assessments that will inform service implementation in at least all 34 of Namibia's district hospitals.

In Namibia, MC services will be primarily supported with PEPFAR funding in COP 09.

Blood Safety

Blood safety is a core component of the USG Namibia prevention service package, and since 2004 USG Namibia has supported

Namibia's blood safety initiatives. The Blood Transfusion Service of Namibia (NAMBTS) is responsible for collection, screening,

and distribution of safe blood and blood products throughout Namibia. The USG established a direct funding relationship with

NAMBTS in FY04. USG also supports technical assistance from WHO which has included an initial program needs assessment

and the placement of a WHO technical advisor to assist NAMBTS and the MOHSS to strengthen the National Blood Program.

The NAMBTS national transfusion center in Windhoek operates within leased MOHSS facilities and achieves cost-recovery

through charging service fees to the 41 health facilities that use blood and blood products. All donated blood is collected from

voluntary, non-remunerated blood donors, and is tested for the following TTI markers: anti-HIV 1 & 2; anti-HCV; HBsAg; NAT

(single sample test) for HIV, HCV and HBV; and syphilis. These tests are carried out by the South African National Blood Service

in Johannesburg.

The initial (2005) estimate of the blood requirement for Namibia was 22,000 units per annum. This estimate was based on the fact

that with 18,500 collections per year, shortages were still being experienced. Due to improved planning, blood distribution,

component preparation (particularly the preparation of paediatric red cell units) and targeted blood collections, NAMBTS has been

largely successful in meeting all requests in the past twelve months, with the exception of some shortages reported in the month

of December. The current annual estimate, determined on the basis of requests received, is now 17,500 units per year.

With PEPFAR support, "Guidelines for the Appropriate Use of Blood and Blood Products in Namibia" has been released (2006),

and a National Blood Policy was developed (2007). The Strategic Plan for the Implementation of the National Blood Policy

2007/2008 to 2009/2010 was finalized and released during June 2008 (on World Blood Donor Day).

The main challenges that NAMBTS continues to face are recruitment and retention of a pool of regular voluntary, non-

remunerated blood donors from low-risk populations, insufficient staff to recruit and counsel donors, and an inadequate transport

network for the distribution of blood and blood products to some parts of the vast country. The Namibia Institute of Pathology

(NIP) is tasked by the MoHSS to provide transfusion laboratory services in areas where NAMBTS does not have a laboratory

network. Under the recently approved National Blood Policy, the provision of equipment, reagents and training for the National

Blood Program becomes the responsibility of NAMBTS. This Policy, which clearly defines the roles and responsibilities of all

parties, will be implemented over the next three years.

COP 09 will be the fifth and final year of Track 1 central funding for Blood Safety activities. COP 09 activities will focus on

consolidating the gains achieved over the past four years with continued training of NAMBTS, MoHSS, and NIP staff on their

respective responsibilities in quality management, component production, and counseling of clients; supervisory skills

improvement, and assessment of the cost-effectiveness of localizing testing of donor blood for transfusion transmitted infections

(TTI). NAMBTS will explore opportunities to ensure program sustainability, such as further refining quantification of demand for

blood and blood products, and potential efficiencies of importation and exportation of blood products.

Injection Safety

Injection safety and waste management initiatives in Namibia have, since 2004, been supported by USG/Namibia. Injection safety

and waste management activities in Namibia are based on results of an assessment done in 2004 by University Research Co.,

LLC (URC) together with the Ministry of Health and Social Services (MOHSS), and in partnership with WHO and UNICEF. The

baseline assessment showed over-prescription of medical injections and a lack of consistent waste disposal procedures, among

others findings. In 2005 URC conducted an assessment on perceptions and attitudes towards injections that showed that the

great majority of the population believes that injection is better than oral medication and that they request injections accordingly.

URC has supported MOHSS to operationalize the National Standard Treatment Guideline (NSTG) which rationalizes the use of

injections.

With USG Track 1 funding URC has assisted the MOHSS to develop and create an enabling environment for safe injection and

waste management practices in the country. Twelve of thirteen regions have developed waste management guidelines while

national waste management policy has been developed. A module on disposal of pharmaceutical waste management is pending

before the policy document is finalized.

URC has been working closely with MOHSS Quality Standards Department (QSD) to build capacity of MOHSS staff to take over

injection safety and waste management activities. By the end of COP 07 staff from four regions had been enabled to conduct

training and supportive supervision of injection and waste management activities. Staff from additional regions will be graduated in

COP 08. Though there is an overall shortage of staff, the program hopes to transition all injection and waste management

activities to MOHSS in COP 09. This will be dependent on MOHSS being able to have budgetary provision by 2010 MOHSS fiscal

year. URC is working closely with QSD to advocate for the necessary budgetary provision.

All facilities have adopted proper needle stick prevention procedures such as use of barriers when opening vials, removing

needles for multidose vials etc. MOHSS has been supported to accurately quantify and project the need of injection safety boxes.

For sustainability, URC has supported a local producer of safety containers, which are now being produced locally in Namibia.

In COP 08 a total of 5,700 healthcare practitioners (HCP) will have been trained in injection safety and waste management. In

COP 09, a total of 7,700 HCP will be trained. The project will continue to incorporate private practitioners into the program. A

behavior change communication strategy, aimed at reducing demand for injections, is being implemented through a network of

grassroots organizations. In COP 07, 16,179 community members were reached, another 25,000 will be reached in COP 08, and

40,000 are targeted in COP 09.

Significant challenges remain, including insufficient numbers of and improperly functioning incinerators. MOHSS recognizes the

importance of proper waste management. URC, in collaboration with SCMS and MSH/SPS, will assist MOHSS in COP 08 to

conduct an assessment on the status of the incinerators and repair or replace some incinerators. A major problem with

incinerators is lack of trained staff to operate them. URC will support training of incinerator handlers as well as the provision of

personal protective equipment for staff in COP 09.

A major component of injection safety has been infection control, which includes training staff on hand washing, working with

facility management to provide soap dispensers as well as paper towels instead of shared towels, previously the norm. URC will

be working closely with MSH/SPS project which also focuses on infection control through facility therapeutic committees, and

TBCAP to address infection control in TB/HIV clinics to broaden infection control interventions.

Table 3.3.04:

Funding for Biomedical Prevention: Voluntary Medical Male Circumcision (CIRC): $185,000

NEW/REPLACEMENT NARRATIVE

Three randomized controlled trials in sub-Saharan Africa have provided evidence that safe male

circumcision (MC) reduces a male's chances of acquiring HIV infection by roughly 60 percent. MC rates in

southern Africa are generally low and correlate with high HIV prevalence rates, Low MC rates is clearly

identified as one of the drivers of the epidemic in the Southern African region. A regional estimate by the

World Health Organization (WHO) suggests that less than 20 percent of men in the region are circumcised.

In Namibia, the 2006 DHS indicates that the MC rate is at 21%. This effectively categorizes Namibia in the

low MC belt characterized by a high HIV/AIDS prevalence rate.

Despite its new and somewhat controversial nature, MC has been largely well received in Namibia. The

Government of the Republic of Namibia (GRN) has recognized it as having an important role to play in HIV

prevention. The recommendations of the first ever male conference held in Windhoek in 2008 with the

participation of His Excellency the President of the Republic included the adoption of MC as an additional

prevention strategy to be included in the national prevention package. The GRN thus enthusiastically

supports the national roll out of an integrated MC initiative. The Ministry of Health and Social Services

(MOHSS) has set an ambitious goal of offering MC services in 40% of facilities (all three tertiary hospitals

and at least one district hospital per region) by the end of 2008. Although undoubtedly ambitious, this goal

should serve to galvanize political and medical momentum. The MOHSS recognizes that the initiative will

require very careful and sensitive planning, and has recommended that MC be implemented not as a

standalone intervention but rather as part of a national comprehensive prevention package. In early 2007,

the MoHSS created a MC task force with the responsibility to create a national MC strategy with supporting

policies and technical recommendations. Task force members represent MoHSS, USG, UNAIDS, WHO,

and key members of the NGO community including University Research Company, IntraHealth and Nawa

Life Trust (which are also USG-supported partners).

The MOHSS has requested USG support for the MC initiative. To better understand barriers and facilitators

to MC uptake and to properly inform future activities, the FY07 funds from USG and the UNAIDS support

were used to conduct a situational assessment based on WHO's situational analysis toolkit. The situational

assessment included: (1) a desk review and analysis of existing data on male circumcision in Namibia; (2)

qualitative research on current and historical MC practices, the MC acceptability across regions and among

both service providers and potential beneficiaries; (3) an assessment and mapping of current medical

facilities and their ability to carry out safe male circumcisions; (4) a stakeholders' meeting to discuss the

results and consider possible interventions; and (5) a summary report with recommendations. Concurrently,

a costing analysis was conducted to determine the cost and likely impact of providing male circumcision in

Namibia.

With IH staff actively involved in the National Male Circumcision task force, the drive towards full scale up of

safe MC as part of a comprehensive prevention package within the 6 Faith-Based Facilities (FBFs) by COP

FY 2008 will be achieved through advocacy work including media response, education, and information

(evening lectures). These activities will be continued during COP FY 2009 and post FY 09.

The completion of the situational analysis has provided substance to the action framework for service

delivery of MC in selected pilot sites started in COP FY 2008. IH will collaborate with MoHSS, I-TECH as a

training agency and other USG partners, UNAIDS and WHO in the task force in designing and providing a

national training program for health care workers on MC SOP in line with WHO/UNAIDS/JHPIEGO

Technical Manual. The surgical training based on this protocol recommends use of local anesthesia unlike

the current practice in many settings in Namibia. The training will also include amongst others pre- and post

-circumcision counseling and proper follow up care plan to ensure possible complications are monitored and

the recommended six week healing period is observed before clients resume sexual activity.

The initiative might eventually require approved task shifting to senior nurses and midwives to alleviate the

burden on medical doctors in the same model as the IMAI. Accreditation and certification process might be

required to ensure safety and quality assurance for new cadres initially not approved to perform MC in

Namibia.

IH and its partners will ensure the performance improvement and the quality of services will be of high

standard through continuous supervisory and support visits to sites and staff providing services.

Supervisory activities will be included in the current support supervision plan conducted for all program

activities for oversight and mentoring of staff conducting MC. In addition, reports from trained staff and their

organizations will be reviewed quarterly to assess quality of services. IH will work with MOHSS to ensure

availability of MC-related commodities in FBF.

Critical to the success of MC is an appropriate, affordable and culturally sensitive communication strategy

and demand creation tailored to the service availability. IH will work with all communication stakeholders to

respond to the information needs and in the design of IEC materials in order to ensure balanced information

on the prevention role of MC is provided. As part of integration of MC into CT, CT sites will continue to

provide information, education and referral as appropriate.

The MC task force has identified the following elements to be incorporated into the National MC Strategy.

First, the strategy will clearly define: (1) priority populations to receive clinical and counseling services; and

(2) primary and secondary target audiences for sensitization, education, and demand creation; and (3) a

national clinical and communications roll-out plan.

The MOHSS expects that MC clinical provision will be embedded into a package of prevention services that

includes: (1) provider-initiated testing and counseling (PITC) with comprehensive post-test counseling; (2)

STI screening and treatment; (3) counseling on risk reduction behaviors with a focus on partner reduction

and abstinence; as well as (4) condom promotion and provision and appropriate referrals to other health

and social services. As stated, HIV testing will be recommended for all men seeking male circumcision, but

will not be mandatory. Clients testing positive at MC clinics will be linked to care, treatment and support

Activity Narrative: services available in all the FBF. As per current evidence, circumcising HIV positives men has no impact on

the epidemic. However, a non-discrimination approach recommended by WHO will be followed. This

requires that, when not medically contraindicated on the basis of poor clinical and immunological staging,

HIV positive men should not be denied circumcision for their own hygienic and other health benefit. All

communications efforts whether in mass media or community or clinical settings will employ messages that

target male norms, the ABC prevention strategy, and sexual violence against women.

Although the USG funding cannot support traditional MC providers to perform circumcisions, it is imperative

to prioritize traditional MC providers for information and education as key community gatekeepers and

ensure an open dialogue that can allow making their practice safe. This is justified by the findings that more

than 62% of men currently circumcised in Namibia have been through traditional providers.

Additionally, the MC task force is advocating with the national insurance body Medical Aid to include adult

MC within its insurance package. Right now, adult MC is only covered by the governmental health

insurance (PSEMAS) when indicated for medical reasons, and the cost of private circumcision services is

prohibitive for most Namibians.

Strategic information on MC will be essential to guide and monitor scaling-up of the service. This will

support the development and dissemination of best practices as well as providing essential information for

program implementers and policy makers. As the service is rolled out and advocated in country, service

provision indicators will need to be incorporated into the routine monitoring and evaluation process. In

addition, specific process evaluation activities will be carried out to guide design of service provider training

curriculum and to optimize IEC campaigns to create demand for MC in the general population and to create

commitment among service providers.

New/Continuing Activity: Continuing Activity

Continuing Activity: 19394

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

19394 19394.08 U.S. Agency for IntraHealth 7361 3078.08 The Capacity $137,500

International International, Inc Project

Development

Emphasis Areas

Gender

* Addressing male norms and behaviors

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $18,500

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.07:

Funding for Care: Adult Care and Support (HBHC): $605,213

NEW/REPLACEMENT NARRATIVE

This is an ongoing activity and includes six elements: (1) clinical care; (2) spiritual care; (3) psychological

and social care; (4) integration with other services; (5) addressing challenges to referrals; and (6) improved

nutritional care.

1. Clinical Care: Capacity is supporting implementation of the clinical components of the preventive care

package and clinical treatment in the five Faith Based Facilities (FBF) and six health centers/clinics in

Namibia. In COP09, support will be provided to continue implementation of the following elements of clinical

palliative care in FBF facilities: prevention and treatment of OIs (CTX prophylaxis for eligible HIV positive

clients and HIV exposed infants and TB screening); INH prophylaxis (on eligibility criteria with increasing

number since mid FY 2007); pain and symptoms management (including opioids), nutritional assessment

and multi micronutrient supplementation; and screening, treatment referral for other conditions such as

malaria and diarrheal disease. CAPACITY staff are active members of the National Palliative Care Task

Force. The Task Force will continue to advocate for increased availability and use of opioids and promote

the use of pediatric formulations at different health facilities. While access is available in select areas the

lack of awareness and training on opioid use is inhibiting rollout of pain control. The program will continue

working with the Task Force for scale up of sensitization, training, clinical mentoring and supportive

supervision for wider expansion of pain management.

2. Spiritual Care: During COP09, spiritual care for PLWHA through trained clergy will continue to allow

PLWHA to express their feelings and spirituality in order to alleviate psychological burden and improve

coping capabilities. End of life care, including hospice care, will also be reinforced through skills update with

I-TECH as they update their training module on palliative care with help from the African Palliative Care

Association (APCA) and the National Palliative Care Task Force. CAPACITY will continue supporting the

TOT training of clergy (with APCA materials) to ensure a qualified pool of clergy who will be equipped

(communication skills and appropriate messaging) to support the spiritual component of palliative care for

the HIV clients, their families and care-givers. Prior to this training, a baseline KAP study will determine the

training needs amongst clergy and will be used to assess the impact of the intervention.

3. Psychological and Social Care: CAPACITY and its partners will work through the referral network to

ensure a proper and strengthened referral system that enables referral of PLWHA and families to the

providers of governmental social services and NGOs such as CAA, ELCIN, and ELCAP, among others for

psychological and social support (social grants, community-based programs and food security programs).

4. Integration with Other Services: During COP09, clients and their families will continue to be provided with

high quality counseling and testing (CT), mainly through provider-initiated prevention counseling. Topics

include encouraging family enrollment into HIV services and behavioral counseling through ongoing

prevention messages (safer sex, reduction of partners and risky behavior) that are integrated into care and

treatment settings as well as referral for support groups' activities (3 of 5 districts have functional support

groups). Family planning counseling, STI screening and treatment will form part of the PwP approach as

every client registered in care will be offered this service at every visit in the same integrated approach, as

for TB screening. The new ART client monitoring tool endorsed by the MoHSS captures data on family

members and partners (tested or not) that will help in providing clients and their families with the basic

preventive package in a family-focused approach. In addition, this tool allows registration of all diagnosed

HIV+ clients in what is called a pre-ART register that includes elements of clinical palliative care, provides

opportunities for routine clinical and immunological follow ups, and lays ground work for optimal time of ART

initiations. Pregnant women enrolled in the PMTCT program are also targeted for PC services. They are

provided with the same basic preventive care package as described earlier, with emphasis on couple

counseling, and safer sex (including during pregnancy and breast-feeding). In general, entry to care for

women is facilitated through PMTCT. Use of TB, STI clinics and possibly male circumcision services will be

likely to canvass for more men and increase their participation.

5. Addressing Challenges to Referrals: During COP09, CAPACITY will work with the USAID to evaluate the

outcome of transport vouchers piloted during COP08. In COP09, CAPACITY is focusing on improving the bi

-directional referral to ensure the continuum of care in the FBF. This activity will be continued in COP09 to

ensure increased collaboration with all CBOs, maintenance of directory of district home-based palliative

care service providers, provision of a platform to discuss referral mechanisms and education of missed

opportunities. Where applicable, DAPP will be engaged to explore areas of strengthening care services

through its Total Control of the Epidemic (TCE) program.

6. Improved Clinical Nutrition: During COP09, CAPACITY will support its partners in reviewing progress of

the Kitchen Corner Initiative which was piloted in two FBF in 07. Without decentralized nutrition/HIV

expertise in Namibia to address nutritional and dietary aspects of HIV/AIDS, this initiative is aimed at

providing nutritional counseling and assessment, follow up of growth monitoring of HIV exposed babies,

education and demonstration, and promotion of safe food and hygiene practices for clients enrolled in care

and treatment. Capacity Namibia will reinforce nutritional messages (including safe infant and young child

feeding strategies), promote use of local food, ensure all IEC materials are available and conduct in-service

training on nutrition and HIV. Technical support in nutrition and HIV will be provided by the ITECH Nutrition

Advisor and the MoHSS.

Building on COP07 and COP08 success, CAPACITY will continue to collaborate with the MoHSS, other

USG partners (CDC/ITECH) and the HIV Clinicians Society (HCS) in facilitating palliative care training (~75

HCW during COP09) with special emphasis on pain assessment and management. An opportunity to

improve overall palliative care practice in the private sector is provided through engaging private

practitioners during these trainings.

Based on a catchment population of about 390,000 for all FBF across 5 regions, and with an average HIV

prevalence rate of 20%, it is estimated that about 39,000 adults are living with HIV/AIDS. By the end of

COP09, FBF will be providing clinical palliative care to 19,360 (~50%) while 17,056 (43%) will be receiving

Activity Narrative: HAART. CAPACITY will continue to ensure provision of high quality service through the use of information

provided by the ART patient monitoring system, regular supportive supervision, and site visits.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16133

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16133 4735.08 U.S. Agency for IntraHealth 7361 3078.08 The Capacity $762,015

International International, Inc Project

Development

7404 4735.07 U.S. Agency for IntraHealth 4406 3078.07 The Capacity $641,265

International International, Inc Project

Development

4735 4735.06 U.S. Agency for IntraHealth 3078 3078.06 The Capacity $592,228

International International, Inc Project

Development

Emphasis Areas

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

* Increasing women's access to income and productive resources

* Increasing women's legal rights

Health-related Wraparound Programs

* Child Survival Activities

* Family Planning

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $48,418

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $6,000

and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.08:

Funding for Treatment: Adult Treatment (HTXS): $1,788,697

NEW/REPLACEMENT NARRATIVE

Under treatment, care and support, the Capacity Project supports six ART service outlets run by the

Catholic Health Services (CHS), the Lutheran Medical Services (LMS) and Angelican Medical Services

(AMS), in rural and semi-urban settings, managing both adult and pediatrics patients, and aiming to expand

access to all persons who need ART services. These services are integrated with VCT and PMTCT in a

model of care allowing close collaboration and strong linkages. An ART pharmacy is on site at each

location. Through September 2008, 14,779 patients were started on treatment in these facilities; 3030

(20.5%) were children and 10429 (70.5%) were females. To increase male participation during FY08, CP

supported sites to use community mobilization campaigns including male conferences, PMTCT invitations

and repeated messages addressing male norms

By the end of September 2008, data indicate that 80% of patients starting HAART in the 5 Faith Based

Hospitals (FBH) were still receiving it (11,831 out of 14,779), leading productive lives, their health status

having improved. To keep pace with change, CP will train all ART staff in the revised guidelines for viral

load testing at six months for all starting patients and later on based on clinical and immunological criteria.

Smooth cooperation with local Namibia Institute of Pathology (NIP) for specimen collection will be ensured.

Furthermore, CP will partner with MSH to pilot adherence monitoring tools in all FBH to deal promptly with

poorly adherent patients while also increasing efforts in active defaulter tracing using all available

resources. ARV drug resistance monitoring will be done by NIP in collaboration with WHO and other USG

partners. CP-supported sites will offer their collaboration and advocate to be part of selected sites.

Given the changes and complexity in ART provision, training and continued medical education remain a

cornerstone in achieving high quality. Based on the updated guideline, CP will collaborate with its

implementing partners to strengthen and update the standard operating procedures (SOPs) to ensure

adherence to quality. As part of its continued Public Private Partnership (PPP) initiative, CP will continue to

ensure that private clinicians and private pharmacists, whom we reach through professional interest

organizations, are adequately trained and updated on the national ART guidelines to provide high quality

HIV care in the private sector. During COP FY 2009, 183 health care workers (HCW) are expected to be

trained. CP staff and its partners will continue to be involved in the Technical Advisory Committee activities

for continuous review of the ART guidelines and will also assist as facilitators in most of the training

sessions across the country for both private and public HCWs.

During COP FY 2009, this activity will increase access to HIV chronic care and maintain rapid scale-up of

effective ART and prevention services. All service delivery points in the facilities will continue to be made

aware of active rather than passive case findings and referral mechanism for in-patients, TB patients, STI

patients, PMTCT mothers, young children from MCH services with signs and symptoms or HIV exposed

infants. HCW will continue to be updated in provider-initiated HIV testing and counseling (PITC) approach.

The continuum of care will be facilitated by ensuring effective referral mechanism with community health

care providers.

In the CP supported standalone VCT sites (ten in eight regions across Namibia), referral mechanism will

continue to be strengthened to ensure all HIV + clients are enrolled into care and treatment services through

confidential rather than anonymous referral.

Capacity of the ART sites to receive and manage referral from standalone VCT facilities will be enhanced

by designating case managers who will guide the patients through the process. The case managers will

also track and give feedback to the referring units. The referred HIV+ patients will continue to be offered

ongoing adherence counseling; clinical assessment; CD4 testing; opportunistic infection (OI) prophylaxis

and treatment, screening for TB, palliative care i.e. pain control, hospice care (terminal care), etc; nutritional

assessment as well as assessment of ART eligibility. A facility-based prevention with positives (PwP)

initiative involving interventions to reduce the spread of HIV to sexual partners (consistent and correct

condoms use especially for discordant couples, and partner reduction, FP counseling and STI screening

and treatment) and to children (PMTCT, family planning), disclosure, comprehensive individual and family

care that addresses the physical, and psychological well being of HIV infected person will be officially

initiated during FY 2008 in FBH treatment sites and further, CP will support the MOHSS' national roll-out.

The PwP also includes the Brief Motivational Interviewing which is being piloted in Rehoboth ART site and

Oshikuku during FY07 with the aim to reduce risky alcohol drinking among patients in HIV related services.

To ensure successful implementation of the PwP initiative and support MOHSS' efforts in strengthening

prevention and treatment responses, CP recruited prevention director will continue working with MoHSS,

USG partners and Capacity partners to ensure that age appropriate prevention messages are offered to

PLWHA and their families and care-givers.

All HIV+ patients not eligible yet for ART will be followed on a regular basis (at least every 6 months) to

ensure they continue to receive a comprehensive care package and ART as needed in a timely way. The

quality of care will be assured through the above mentioned ART system that comprises the pre-ART and

the ART registers. The pre-ART register (care register) is intended to register in continuous care all HIV+

from diagnosis to treatment initiation aiming at routine clinical and immunological monitoring and provision

of basic health care package. The system is also designed to generate a monthly cohort analysis that can

be used locally, regionally and at the national level for effective patient and program monitoring with

feedback to all sites. Platforms such as the national review meeting initiated by MOHSS and individual

partner review meeting such as FBH review meetings will serve to share lessons learned and disseminate

best practices.

In addition, all patients enrolled in the care program will receive support and referral for other needs not

provided in the care package, such as income generating activities, spiritual support, psychological support,

community based palliative care services and OVC as per identified needs.

Once eligible for HAART initiation, patients are provided with HAART as per the national guidelines,

transferred in the ART register and followed up accordingly. During COP FY 2009, the national

Activity Narrative: decentralization of ART service is expected to gain more momentum. CP will support the referral systems

whereby the clinically stable patients will be cared for through satellite health facilities by Integrated

Management of Adults & Adolescents Illness (IMAI) trained staffs. FBH staff will continue to support and

transfer knowledge to other HCW from satellite facilities while training, supervision and clinical mentoring

will be assured through performance improvement approaches. In view of the growing number of patients

enrolled in care, consultations with MOHSS will continue to consider piloting task-shifting, whereby nurses

in the ART sites will be empowered to fully care for stable patients prescribing refills under the supervision

of the ART medical officers.

All CP supported partners will continue community awareness, mobilization and education to create

demand for the available ART services under the supervision of the Capacity prevention director with

collaboration with Nawa-Life Trust. This will involve other stakeholders such as community-based and faith-

based organization, traditional leaders and healers, church leaders, teachers, youth groups, support groups

as well as members of the regional and constituency aids committees.

The program sustainability will be ensured through continuous training of indigenous HCW and the technical

support provided to the MOHSS Human Resource Information System (see OHSS area).

New/Continuing Activity: Continuing Activity

Continuing Activity: 16136

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16136 4737.08 U.S. Agency for IntraHealth 7361 3078.08 The Capacity $2,178,394

International International, Inc Project

Development

7406 4737.07 U.S. Agency for IntraHealth 4406 3078.07 The Capacity $1,743,477

International International, Inc Project

Development

4737 4737.06 U.S. Agency for IntraHealth 3078 3078.06 The Capacity $1,718,268

International International, Inc Project

Development

Emphasis Areas

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

Health-related Wraparound Programs

* Child Survival Activities

* Family Planning

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $143,096

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.09:

Funding for Care: Pediatric Care and Support (PDCS): $106,802

NEW/REPLACEMENT NARRATIVE

This is an ongoing activity and includes seven elements: (1) clinical care; (2) spiritual care; (3) expansion of

pediatric care; (4) psychological and social care; (5) integration with other services; (6) addressing

challenges to referrals; and (7) improving nutritional care.

1. Clinical Care: By the end of COP FY 2008, Capacity Project (CP) will have supported the implementation

of the clinical components of the preventive care package and clinical treatment in the five Faith Based

Facilities (FBF) and eight health centers/clinics in Namibia. The following elements of clinical palliative care

are delivered in Capacity supported facilities: prevention and treatment of OIs (CTX prophylaxis for eligible

HIV positive children and HIV exposed infants and TB screening); INH prophylaxis (on eligibility criteria with

increasing number since mid FY 2007); pain and symptoms management (including opioids), nutritional

assessment and multi micronutrient supplementation; and screening, treatment referral for other conditions

such as malaria and diarrheal disease. Capacity technical staff are active members of the National Palliative

Care Task Force. The Task Force will continue to advocate for increased availability and use of opioids and

promote the use of pediatric formulations at different health facilities. While access is available in select

areas the lack of awareness and training on opioid use is inhibiting rollout of pain control. Capacity will work

with HIVCS and I-TECH to improve the skills of HCWs on pain assessment for children and pain

management. Capacity will explore distribution of IEC materials produced specially for kids as SAFAIDS

materials. The program will continue working with the Task Force for scale up of sensitization, training,

clinical mentoring and supportive supervision for wider expansion of pain management. All procurements

(pain medications, micronutrients, CTX, etc will be linked to the MoHSS central medical store procurement

system.

2. Spiritual Care: During COP FY 2008, spiritual care for PLWHA through trained clergy will be added to

complement CAPACITY clinical care in order to allow PLWHA to express their feelings and their spirituality

in order to alleviate psychological burden and improve coping capabilities. End of life care, including

hospice care, will also be reinforced through skills update with I-TECH as they update their training module

on palliative care with help from the African Palliative Care Association (APCA) and the National Palliative

Care Task Force. CAPACITY will initiate and support the TOT training of clergy (with APCA materials) to

ensure a qualified pool of clergy who will be equipped (communication skills and appropriate messaging) to

support the spiritual component of palliative care for the HIV clients, their families and care-givers. The

result of KAP study will determine the training needs amongst clergy and will be used to assess the impact

of the intervention. Capacity will explore these training needs with other USG partners as CAA, CHS, LMS,

ELCAP and ELCIN.

3. Pediatric Expansion: Building on a relatively good trend of pediatric ART uptake (16.9% of all ART users

with FBH "2003 out of 11831 according to Capacity COP FY 2007 APR), CAPACITY-supported sites will

aim at maintaining the pediatric palliative care priority by increasing entry points to care and treatment.

These include PMTCT services, in-patient and out-patient departments (early presumptive diagnosis), TB

clinics and MCH services. From the 6th week of age, HIV exposed infants are provided with CTX as per

national guidelines. However, tracing infants missing follow up visits remain a major challenge to the

program. Many factors are contributing to the defaulting of a number of HIV exposed children such as

distances, transport costs, and migration of parents. Follow ups in nearby health facilities are being done for

some of them but the weak reporting linkages between different satellite facilities and the ART/PMTCT site

limit the flow of data. The coverage of CTX prophylaxis among the HIV positive pediatric clients receiving

care in the FBH is above 80%. Also, this activity will support diagnosis and management of malaria in

endemic regions according to the guidelines of the National Malaria Control Program. In addition, infant

feeding counseling, micronutrient supplement, access to early infant diagnosis (DNA-PCR at 6th week as

per current algorithm), assessment and management of pain and linkage to routine child care

(immunization, Vitamin A, growth monitoring and promotion) will be actively provided.

4. Psychological and Social Care: CAPACITY and its partners will work through the referral network to

ensure a proper and strengthened referral system that enables referral of children, their care givers and

families to the providers of OVC governmental services and NGOs such as CAA, ELCIN and ELCAP

among others for psychological and social support (social grants, community based programs and food

security programs). To appropriately cover psycho-social needs of children affected and/or infected by HIV,

CAPACITY will continue to support training of HCW in the FBH and MoHSS sites using the child counseling

curriculum developed in COP FY 2007 in collaboration with other training partners.

5. Integration with Other Services: During COP FY 2009, clients and their families will continue to be

provided with high quality counseling and testing (CT), mainly through provider-initiated prevention

counseling. Topics include encouraging family enrollment into HIV services (family-centered approach) and

behavioral counseling through ongoing prevention messages( age appropriate messages) that are

integrated into care and treatment settings as well as referral for support groups activities (3 of 5 districts

have functional support groups). PwP approach including TB screening and management, INH prophylaxis,

nutritional counseling and knowledge through kitchen corners will be strengthened through continuation of

training, support and supervision by CAPACITY prevention director and prevention team. The new ART

patient monitoring tool endorsed by the MoHSS captures data on family members and partners (tested or

not) that will help in providing clients and their families with the basic preventive package in a family-focused

approach. In addition, this tool allows registration of all diagnosed HIV+ clients in what is called a pre-ART

register that includes element of clinical palliative care and gives opportunity for routine clinical and

immunological follow up and lays ground work for optimal time of ART initiation. Pregnant women enrolled

in the PMTCT program are also targeted for PC services.

6. Addressing Challenges to Referrals: During COP FY 2009, CAPACITY will work with the USAID to

evaluate the need of transport vouchers piloted during COP FY 2008 taking in consideration the roll out of

IMAI services in different health centers and clinics and the increase of the number of service outlets

providing care and support to 19 sites during COP07 as a result of favorable policy environment allowing

rapid roll-out.

Activity Narrative: In COP FY 09, CAPACITY is focusing on improving the bi-directional referral to ensure the continuum of

care in the FBF. This activity will be continued in COP FY 2010 to ensure increased collaboration with all

CBOs, maintenance of directory of district home-based palliative care service providers, providing a

platform to discuss referral mechanisms and education of missed opportunities. Where applicable, DAPP

will be engaged to explore areas of strengthening care services through its Total Control of the Epidemic

(TCE) program.

7. Improved Clinical Nutrition: Every HIV infected child enrolled in care will be assessed in every follow up

visit for weight and height and his/her body mass index (BMI) is electronically calculated by the ePMS,

screened for nutrition-related symptoms (e.g. appetite, nausea, thrush, diarrhea) and counseled by HCW for

proper nutrition and diet. As mentioned earlier, this activity will support provision of a daily multi-

micronutrient supplement for children whose diets are unlikely to meet vitamin and mineral requirements.

For children with significant malnourishment status will be admitted in the inpatient wards to receive the

recommended therapeutic and supplementary feeding. Furthermore, during COP FY 2009, CAPACITY will

support its partners in reviewing progress of the Kitchen Corner Initiative which was piloted in two FBH in

COP FY 2007. Without decentralized nutrition/HIV expertise in Namibia to address nutritional and dietary

aspects of HIV/AIDS, this initiative is aimed at providing nutritional counseling and assessment, follow up of

growth monitoring of HIV exposed babies, education and demonstration, and promotion of safe food and

hygiene practices for clients enrolled in care and treatment. Capacity Namibia will reinforce nutritional

messages (including safe infant and young child feeding strategies), promote use of local food, ensure all

IEC materials are available and conduct in-service training on nutrition and HIV. Technical support in

nutrition and HIV will be provided by the ITECH Nutrition Advisor and the MoHSS.

Building on COP FY 2007 and COP FY 2008 success, CAPACITY will continue to collaborate with the

MoHSS, other USG partners (CDC/ITECH) and the HIV Clinicians Society (HCS) in facilitating palliative

care training (~20 HCW during COP FY 2009) with special emphasis on pediatrics pain assessment and

management. An opportunity to improve overall palliative care practice in private sector is provided through

engaging private practitioners during these trainings.

Based on a catchment population of about 390,000 for all FBF across 5 regions, 38.9% are children less

than 14 years of age and with an average HIV prevalence rate of 7% among children, it is estimated that

10,620 children are living with HIV/AIDS. By the end of COP FY 2009, FBF will be providing clinical

palliative care to 5,300 (50%) while 2,550 (48%) children will be receiving HAART. CAPACITY will continue

to ensure provision of high quality service through the use of information provided by the ART patient

monitoring system, regular supportive supervision, and site visits.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16133

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16133 4735.08 U.S. Agency for IntraHealth 7361 3078.08 The Capacity $762,015

International International, Inc Project

Development

7404 4735.07 U.S. Agency for IntraHealth 4406 3078.07 The Capacity $641,265

International International, Inc Project

Development

4735 4735.06 U.S. Agency for IntraHealth 3078 3078.06 The Capacity $592,228

International International, Inc Project

Development

Emphasis Areas

Health-related Wraparound Programs

* Child Survival Activities

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $8,545

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.10:

Funding for Treatment: Pediatric Treatment (PDTX): $326,759

NEW/REPLACEMENT NARRATIVE

IntraHealth/Namibia, the Capacity Project is expecting as a result of its COP FY 2006/ 07/08 capacity

building process to transition to direct funding Catholic Health Services (CHS) in COP FY 2009. Pending

results of the required pre-award survey (responsibility determination), including a financial/organizational

capacity evaluation and availability of FY09 funding, i.e., continuing resolution (CR), CHS may initially have

to enter into a ‘Leader with Associates Award' under IntraHealth and move to direct funding when it meets

all eligibility requirements under USAID's Acquisition and Assistance regulations. This process will ensure

the continuity of program activities. The direct funding mechanism will replace the Associates Award and be

implemented as soon as CHS is deemed eligible and approved by the Pretoria USAID Regional Contracting

office.

Under treatment, care and support, the Capacity Project supports 19 ART service outlets run by the

Catholic Health Services (CHS), the Lutheran Medical Services (LMS) and Angelican Medical Services

(AMS), in rural and semi-urban settings, managing both adult, and pediatrics patients, and aiming to expand

access to all persons who need ART services. These services are integrated with VCT and PMTCT in a

model of care allowing close collaboration and strong linkages. An ART pharmacy is on site at each location

except for Odibo HC. Through September 2008, 14,779 patients were started on treatment in these

facilities; 3030 (20.5%) were children and 10429 (70.5%) were females. To increase male participation

during COP FY 2008, CP supported sites to use community mobilization campaigns including male

conferences, PMTCT invitations and repeated messages addressing male norms. Capacity supported sites

will continue exploring and providing male friendly services.

Good pediatric ART trends will continue through strengthened linkages between entry points such as

PMTCT and outpatient and inpatient departments with ART services, as well as with Maternal and Child

Health Services. The updated WHO guidelines for initiating HAART to every HIV positive child less than 1

year old will be strengthened through training and refresher training for HCW both in public and private

sectors. Early infant Diagnosis (EID) utilizing DNA PCR will be used to identify children less than one year

for treatment. Counseling and psycho-social support for children will be enhanced with the training program

being finalized during COP FY 2008.

Data indicate by the end of September 2008, that 66% of pediatric patients started HAART in the 5 Faith

Based Hospitals (FBH) were still receiving it (2003 out of 3030), leading productive lives, their health status

having improved. To keep pace with change, CP will train all ART staff in the revised guidelines for viral

load testing at six months for all starting patients and later on based on clinical and immunological criteria.

Smooth cooperation with local Namibia Institute of Pathology (NIP) for specimen collection will be ensured.

The initiation of the new guidelines to start HAART for HIV positive children less than 1 year of age will

definitely decrease morbidity and mortality among this vulnerable group. To further increase the quality of

pediatric HIV care, Capacity supported partners will further strengthen the family-centered approach to

facilitate early diagnosis and management of pediatric HIV cases and improve adherence to treatment. The

family- centered care improves the ability to address the multigenerational effects of HIV, integrate care,

decrease stigma and promote family wellness benefiting infants, children, adolescents and their parents.

Furthermore, CP will partner with MSH to pilot adherence monitoring tools in all FBH to deal promptly with

poorly adherent patients while also increasing efforts in active defaulter tracing using all available

resources. ARV drug resistance monitoring will be done by NIP in collaboration with WHO and other USG

partners. CP-supported sites will offer their collaboration and advocate being part of selected sites. Capacity

will explore distribution of IEC materials produced specially for kids as SAFAIDS materials which increase

the knowledge in an age appropriate message for children affected and infected by HIV.

Given the changes and complexity in ART provision, training and continued medical education remain a

cornerstone in achieving high quality. Based on the updated guideline, CP will collaborate with its

implementing partners to update the standard operating procedures (SOPs) to ensure adherence to quality.

As part of its continued Public Private Partnership (PPP) initiative, CP will continue to ensure that private

clinicians and private pharmacists, whom we reach through professional interest organizations, are

adequately trained and updated on the national ART guidelines to provide high quality HIV care in the

private sector. During COP FY 2009, 183 HCW are expected to be trained. CP staff and its partners will

continue to be involved in the Technical Advisory Committee activities for continuous review of the ART

guidelines and will also assist as facilitators in most of the training sessions across the country for both

private and public health care workers (HCW).

During COP FY 2009, to increase access to HIV chronic care, and maintain rapid scale-up of effective ART

and prevention services. All service delivery points in the facilities will continue to be made aware of active

rather than passive case findings and referral mechanism for in-patients, TB patients, HIV exposed infants

(MTCT), young children from MCH services with signs and symptoms or HIV exposed infants. HCW will

continue to be updated in provider-initiated HIV testing and counseling (PITC) approach. The continuum of

care will be facilitated by ensuring effective referral mechanism with community health care providers.

In the CP supported standalone VCT sites (ten in eight regions across Namibia), referral mechanism will

continue to be strengthened to ensure all HIV + clients are enrolled into care and treatment services through

confidential rather than anonymous referral.

Capacity of the ART sites to receive and manage referral from standalone VCT facilities will be enhanced

by designating case managers who will guide the patients through the process. The case managers will

also track and give feedback to the referring units. The referred HIV+ patients will continue to be offered

ongoing adherence counseling; clinical assessment; CD4 testing; opportunistic infection (OI) prophylaxis

and treatment, screening for TB, palliative care i.e. pain control, hospice care (terminal care), etc; nutritional

assessment as well as assessment of ART eligibility. A facility-based prevention with positives (PwP)

initiative involving interventions to reduce the spread of HIV to children (PMTCT, family planning),

disclosure, comprehensive individual and family care that addresses the physical, and psychological well

being of HIV infected person will be strengthened during COP FY 2009 in FBH treatment sites and further,

Activity Narrative: CP will support the MOHSS' national roll-out.

All HIV+ children not eligible yet for ART will be followed on a regular basis (at least every 6 months) to

ensure they continue to receive a comprehensive care package and ART as needed in a timely way. The

quality of care will be assured through the above mentioned ART system that comprises the pre-ART and

the ART registers. The pre-ART register (care register) is intended to register in continuous care all HIV+

from diagnosis to treatment initiation aiming at routine clinical and immunological monitoring and provision

of basic health care package. The system is also designed to generate a monthly cohort analysis that can

be used locally, regionally and at the national level for effective patient and program monitoring with

feedback to all sites. Platforms such as the national review meeting initiated by MOHSS and individual

partner review meeting such as FBH review meetings will serve to share lessons learned and disseminate

best practices.

In addition, all patients enrolled in the care program and their families will receive support and referral for

other needs not provided in the care package, such as income generating activities, spiritual support,

psychological support, community based palliative care services and OVC as per identified needs.

Once eligible for HAART initiation, patients are provided with HAART as per the national guidelines,

transferred in the ART register and followed up accordingly. During COP FY 2009, the national

decentralization of ART service is expected to gain more momentum. CP will support the referral systems

whereby the clinically stable patients will be cared for through satellite health facilities by Integrated

Management of Children Illness (IMCI) trained staffs. FBH staff will continue to support and transfer

knowledge to other HCW from satellite facilities while training, supervision and clinical mentoring will be

assured through performance improvement approaches. In view of the growing number of patients enrolled

in care, consultations with MOHSS will continue to consider piloting task-shifting, whereby nurses in the

ART sites will be empowered to fully care for stable patients prescribing refills under the supervision of the

ART medical officers.

All CP supported partners will continue community awareness, mobilization and education to create

demand for the available ART services. This will involve other stakeholders such as community-based and

faith-based organization, traditional leaders and healers, church leaders, teachers, youth groups, support

groups as well as members of the regional and constituency aids committees.

The program sustainability will be ensured through continuous training of indigenous HCW and the technical

support provided to the MoHSS Human Resource Information System (see OHPS area).

New/Continuing Activity: Continuing Activity

Continuing Activity: 16136

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16136 4737.08 U.S. Agency for IntraHealth 7361 3078.08 The Capacity $2,178,394

International International, Inc Project

Development

7406 4737.07 U.S. Agency for IntraHealth 4406 3078.07 The Capacity $1,743,477

International International, Inc Project

Development

4737 4737.06 U.S. Agency for IntraHealth 3078 3078.06 The Capacity $1,718,268

International International, Inc Project

Development

Emphasis Areas

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

Health-related Wraparound Programs

* Child Survival Activities

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $26,140

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.11:

Funding for Care: TB/HIV (HVTB): $65,422

NEW/REPLACEMENT NARRATIVE

In the faith-based hospitals (FBHs), TB clinics are directly managed by the Ministry of Health and Social

Services (MoHSS) while Odipo health center serves as a Directly Observed Therapy site. The TB clinics are

linked to counseling and testing (CT) sites in their respective hospitals, either under the same roof or

nearby. All patients accessing services from other hospitals departments (inpatients, special clinics and

OPD outpatients) are evaluated for TB and offered HIV C&T. In the 4 Catholic Health Services (CHS)

hospitals, the TB wards have certified sites for counseling and rapid HIV testing and have trained staff to

conduct the tests. In the Lutheran Medical Services LMS, the TB clinic is housed in the same building as

C&T, allowing for close physical and operational linkages. The close collaboration of the hospital TB clinics

and CT sites in all FBHs allows a successful referral system between TB clinics and HIV services (CT, care

and treatment) and facilitates routine CT for majority of TB patients.

As part of the TB/HIV collaborative activities, Intrahealth (IH) will support regular monthly meetings between

the TB program staff and the ART site staff to discuss issues related to referral, data collection and

completeness, and other programmatic issues. In the ART sites and PMTCT rooms in the faith-based

facilities, Capacity will continue to update staff skills on screening HIV patients for TB in every follow up

visit, clinical monitoring of the patients during consultations, referral for laboratory services, and offering

Isoniazid prophylaxis to eligible patients in addition to cotrimoxazole prophylaxis, micronutrients

supplementation and CT for other family members. Suspected TB patients are offered clinical examination,

sputum direct microscopy and X-ray when applicable to confirm the TB diagnosis.

Clinical staff from the hospitals, clinics and ART sites will be trained on TB/HIV management in

collaboration with MoHSS and other USG partners (I-TECH). ART clinics staff will be continuously updated

in the identification and management of TB/HIV cases and sensitized to rapidly triage for TB signs and

symptoms and fast-track to TB diagnosis services. History of previous diagnosis and treatment will be

elicited in order to identify suspected MDR cases, and refer them for the necessary laboratory tests and

appropriate treatment. In collaboration with the Tuberculosis Control Assistance Program (TBCAP), IH will

strengthen collaborative TB/HIV activities and doctors in the ART sites will initiate TB treatment for all

confirmed TB cases and subsequently refer the patients to the TB clinic/ward accordingly. Eventually, the

ART and TB management at facilities will be transformed to "one stop shop" for both diseases.

In line with the strategic shift from just HIV testing sites, standalone VCT sites staff will continue TB

screening using standardized questionnaire and will refer accordingly. In COP FY 2009, the nurses in the

standalone VCT sites will continue supporting the lay counselors in TB screening and referral beside the

other clinical tasks.

Oversight of TB screening for pediatric patients is of great concern. HIV-positive children enrolled in the

care and treatment program will be screened for TB in every follow-up visit. Pediatric TB patients and their

care-givers will be offered HIV CT services. For screening of TB, IH-supported facilities will adopt the

national standard operating procedures and operate within the national TB control guidelines. IH will also

work closely with MoHSS on task shifting so that staff members from satellite facilities will be able to refer

patients suspected to have TB and HIV co-infection to the district facilities. These patients will be fast

tracked to confirm or exclude the TB diagnosis.

Due to the high co-morbidity of TB and HIV, infection control measures within ART sites will be enhanced

by ensuring timely diagnosis of suspected TB patients and initiation of treatment to prevent nosocomial

transmission. Faith-Based Facilities (FBF) have been cognizant of the need for proper infection control. For

example, in the extension of the ART sites in the Lutheran Medical Service (LMS), where the TB district

clinic is housed, steps were taken to ensure proper ventilation in the waiting area and consulting rooms

where TB patients are served, reducing the risk of exposure. IH will continue to advocate for such

considerations in facilities renovations and will review all the ART sites to make sure they are appropriate

for infection control.

During COP FY 2009, IH will continue to support the HIV Clinician Society as part of private-public

partnership. The private sector treats about 20% of HIV patients in Namibia. Training of private practitioners

will improve the quality of services rendered and also increase their attention to identifying and appropriately

treating those with TB co-infection. In collaboration with NTCP, 40 private practitioners and 25 HCW from

the public sector, faith-based facilities will be trained on TB/HIV management. Special training emphasis will

be on screening, diagnostic aids and adult and pediatric TB and its management.

Data collection to integrate information on TB and HIV has been a problem. Currently, a reliable tool for

linkage between TB and HIV services, the electronic ART patient monitoring system have been

implemented by the MoHSS according to WHO recommendations. This system captures data on TB and

HIV and allows monitoring and evaluation of the referral system and the quality of the services. Data

collection will be strengthened by regular reviews of data collection tools and data analysis at the facilities

by the ART and TB teams.

In collaboration with TBCAP, regular data review will be undertaken to evaluate the quality of services being

provided. Quality of HIV CT services in the TB units will be undertaken on a regular basis as part of the

facilities quality assurance program which involves supportive supervision by CT and laboratory

supervisors.

The PEPFAR supported program will leverage the MoHSS/Global Fund resources. These Global Fund

resources are used to support personnel and operational costs of the TB program in all districts. Therefore,

IH supported sites will incur minimum TB program cost as the focus will be mainly on areas of training, skill

update, supportive supervision and strengthening of linkages and HIV collaborative activities system.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16134

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16134 7447.08 U.S. Agency for IntraHealth 7361 3078.08 The Capacity $73,422

International International, Inc Project

Development

7447 7447.07 U.S. Agency for IntraHealth 4406 3078.07 The Capacity $9,779

International International, Inc Project

Development

Emphasis Areas

Health-related Wraparound Programs

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $5,234

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.12:

Funding for Testing: HIV Testing and Counseling (HVCT): $3,422,511

NEW/REPLACEMENT NARRATIVE

Since October 2007, IH has been supporting counseling and testing (CT) services through a network of 17

New Start (NS) centers in collaboration with the MoHSS and with funding from the PEPFAR. By the

beginning of COP FY 2009, Capacity will be managing 16 NS centers (10 standalone, 6 integrated). This

includes an additional NS center situated in Windhoek and established at the beginning of COP FY 2008.

IH will scale up CT outreach/mobile activities for all supported sites as per the approved guideline. As a

result, increased number of outlets will be providing CT services to reach communities. With exception of

the CCN NS, sites are managed by NGOs and FBOs making up 10 CT implementing partners. The

partners, operating as franchise members in 10 out of 13 regions of Namibia, provide services under a sub-

agreement with Capacity which in turn provides funding, program oversight, performance support and

technical assistance. This narrative details the continued consolidation of NS services for COP09.

The main objectives during this implementation period will be: 1) to increase the number of first-time clients

who have been counseled and tested for HIV, and received their test results from 65,000 to 105,964, 2) to

strengthen the referral system through an effective client tracking system, 3) to sustain an effective M&E

system through use of a continuous improvement of data management system and 4) to build capacity to

allow partners to graduate for direct funding.

Capacity will continue to support NS Centers focusing more on behavior change interventions through

partnership with C-change. Using the C-change models, CMs will be trained and re-trained on Interpersonal

communications (IPC) and group information sessions. These sessions will aim to communicate messages

that bring about behavior change amongst NS clients. It is proven that group education has indeed

shortened the pre-test counseling time and will continue to allow counselors to focus greater attention on

the post-test counseling with view to develop a client focused risk reduction plan. Multiple concurrent

partnership (MCP) has been identified as one of the key drivers of the epidemic. Hence, a special emphasis

will be drawn on addressing MCP in all post test counseling sessions to foster positive behavioral and social

change.

Capacity will also continue to strengthen the in-room testing approach piloted in COP FY 2008 and to be

rolled under the MoHSS guidance in order to ensure further shortening of waiting time as additional services

are being introduced. Most NS centres will be conducting outreach testing services, therefore reaching

underserved communities in remote areas and/or workplaces. CM staff from the NS centers will visit

communities identified in conjunction with the RACOC's and other local partners and prepare them for the

arrival of the outreach testing team.

The rapid testing activities will be conducted by NIP certified NS staff and will follow the MoHSS protocols

for outreach HIV testing. The NS outreach team will place special emphasis on reaching high risk groups

such as mobile populations as well as respond to requests from communities for outreach testing services.

This service will increase from twice monthly to weekly if community response dictates it. Some sites

currently poorly performing on the client counselor ratio will be assigned primarily the role of outreach

launching pad. Demand for this service will continue to be created by the NS center CMs through local

language radio spots, liaison with traditional, community and political leaders. In facility-based sites, IH will

continue the provision of provider initiated testing and counseling (PITC) as a way of increasing the number

of individuals knowing their HIV status and consequently accessing HIV care and treatment. This approach

which is already successful since COP FY 2006 for PMTCT, TB, STI clients who are routinely offered HIV

testing will be extended and monitored closely to include all clients/patients visiting our health facilities

regardless of reasons of the visit. This screening approach endorsed by WHO applies to Namibia as a

generalized epidemic. An "opt-out" approach will be utilized in order to ensure the testing remains voluntary

and confidential. Proper reporting system will be put in place to document success.

In COP FY 2008, MoHSS planned to review VCT guidelines with special emphasis on Pediatric HIV testing

and counseling. The guidelines are expected to address issues on age of consent, disclosure, training for

health care providers and testing technologies. In COP FY 2009, all six facility based sites under IH will

implement early infant testing, diagnosis, and follow up using the PITC approach. Ultimately, Pediatric HIV

TC will be routinely offered as part of care for infant /child presenting to health facilities with signs,

symptoms or medical conditions that suggests HIV infection. To ensure quality service delivery, all staff will

receive training in child counseling as well as skill building on how to work with families of HIV-infected

children. IH will adopt a family-centered care approach to address the multigenerational effects of HIV,

integrate care, decrease stigma and promote family wellness benefiting infants, adolescent and their

parents.

NS network will be supported to continue to offer the following prevention activities: Men's sexual and

reproductive health including education, information and referral for MC, STI education, screening and

referral, TB screening and referrals, brief motivational interviewing for alcohol, family planning counseling

and referral and where applicable commodities supplied through the MoHSS supply system and lastly some

sites will provide general health information.

In addition, owing to the increased number of marital sex transmission of HIV reported in Sub-Saharan

Africa and a discordant couple rate of about 10% in our dataset, special emphasis will be placed on

increasing the couple counseling skills amongst our counselor, scaling up demand creation for couple

counseling and therefore increase the uptake of couple counseled. Partner testing, notification and

disclosure will be part of a full package of Prevention with positive that will be implemented in all CT sites

using minimum steps approach (STI screening, condoms: correct and consistent use, FP, family testing).

The IH team will continue to partner with NawaLife to expand an aggressive demand creation campaign for

HIV testing. This partnership will focus mainly on mass media communication to increase testing numbers

at both New Start centers and other facilities (MoHSS and public sector). Nawa life will also undertake

region specific promotional campaigns targeting specific communities. Community mobilizers will be used to

Activity Narrative: reinforce messages from the national campaign through outreach activities at Cuca shops, workplaces, etc.

Promotional initiatives such as the popular "win a bicycle campaign" in partnership with BEN Namibia will be

actively pursued as well as capitalizing on the national testing days (NTD) when a huge surge in testing

numbers will always be expected.

In COP FY 2009 the IH will continue to increase quality of CT provision and services through sharpening,

consolidating and updating the training and supervision of CT counselors and developing an effective,

functional and measurable referral system utilizing reliable tools. The management of the NS network at

both IH and implementing partner level will be led by a highly trained and functional team mix of HIV

counselors, medical and social work professionals. Quality of NS services and IH interventions will be

monitored by the MER officer through mystery client surveys, client exit interviews and questionnaires and

focus group discussions (FGD's). The findings from the FGD's will be used to guide NS social mobilization

strategies in collaboration with EngenderHealth and C-Change. In addition, the findings of these FGD's will

be shared with NawaLife and incorporated into the demand creation campaign.

Training and re-training of new start staff will continue and modules to be covered will include, MER and

data management, CT center management training, receptionist training, personal growth, basic and

VCT/TC counseling, couples, child and whole family counseling. These trainings will be done both

internally and through the MoHSS training agency. Special efforts will be made to ensure that accurate

information is understood by NS counselors about the window period, the importance of adequate

prevention counseling with negative testers, TB referrals for all positive testers, alcohol and HIV, gender

based violence and couples counseling strategies. The IH team will continue to reinforce adherence to

standardized minimum hiring requirements for new start staff. Elevated educational and experience

requirements will build quality staffing into all NS sites and adequate salaries will decrease attrition and

inefficient repetition of trainings. As part of gender mainstreaming activities, Capacity will continue to train

all NS staff on male friendly services, male engagement and women vulnerabilities in order to support

positive gender transformation in both individuals and couples. This will be done in collaboration with

EngenderHealth and LL/CL.

The IH will work closely with the MoHSS as a member of the CT technical working group providing

guidance and technical expertise on both clinical and counseling issues. The IH will also continue partnering

with the Namibia Institute of Pathology (NIP) who will provide clinical quality assurance oversight at all NS

sites.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16135

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16135 4736.08 U.S. Agency for IntraHealth 7361 3078.08 The Capacity $3,993,591

International International, Inc Project

Development

7405 4736.07 U.S. Agency for IntraHealth 4406 3078.07 The Capacity $4,014,936

International International, Inc Project

Development

4736 4736.06 U.S. Agency for IntraHealth 3078 3078.06 The Capacity $846,808

International International, Inc Project

Development

Emphasis Areas

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

* Increasing women's legal rights

* Reducing violence and coercion

Health-related Wraparound Programs

* Child Survival Activities

* Family Planning

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $273,800

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.14:

Funding for Testing: HIV Testing and Counseling (HVCT): $421,080

APRIL 2009 REPROGRAMMING: Catholic AIDS Action (CAA), an indigenous Namibian organization, was

earmarked to receive PEPFAR funding as a prime partner for the first time under COP 09. However, CAA

did not pass Defense Contract Audit Agency (DCAA) pre-award survey. They will therefore implement COP

09 activities as a sub-partner under IntraHealth.

---------------------------------------------------

During FY 2009 COP, two CAA sponsored New Start Centers, in collaboration with the Capacity Project at

IntraHealth, the Ministry of Health and Social Services (MoHSS), and Nawa Life Trust, will provide voluntary

counseling and testing services for 11,520 individuals. Since 2003, CAA has worked with the Social

Marketing Association (SMA) and then IntraHealth in the provision of community counseling and testing

services through one free standing VCT center in Windhoek's Katatura section and one in Oshakati Region.

CAA uses the nationally approved algorithm and guidelines for the provision of these voluntary counseling

and testing services which include community outreach mobilization, group support for people living with

HIV, and referrals for additional clinical services such as ART, PMTCT and TB screening and treatment.

Other medical interventions include HIV infection prevention information (including male circumcision),

prevention for positives, support for HIV negative individuals to remain negative and referral to home based

palliative care services through CAA. Designated staff at each center has also been trained in couple

counseling approaches. This encourages both parties to come for testing and mutual disclosure of results.

Each facility also has a registered nurse that can screen clients for other Sexually Transmitted Infections

(STIs) using a syndromic approach. If a client tests positive, they are referred to the closest GRN facility for

ART evaluation and also to the CAA home based palliative care program.

An outreach coordinator at each of the two New Start Centers works with the CAA staff, home care

volunteers, and peer educators to increase demand for VCT services through community education and

mobilization. This outreach occurs in a variety of school, local business, and church settings. CAA

continues to implement a Male Engagement Curriculum in its community education work that specifically

targets men to increase their utilization of VCT.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Gender

* Addressing male norms and behaviors

Health-related Wraparound Programs

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $219,500

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 15 - HTXD ARV Drugs

Total Planned Funding for Program Budget Code: $1,215,324

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Namibia has achieved a very successful roll out of antiretroviral treatment since the inception of its program in 2003, and

exceeded its PEPFAR five-year treatment goal of 23,000 in the third year of PEPFAR implementation. The USG's main

accomplishment in the ARV drug program area has been its ongoing support of the Ministry of Health and Social Services

(MOHSS) in its approach to ARV drug procurement for the public sector. USG funding in this program area now supports just a

single activity: ARV procurement through the MOHSS.

A joint procurement plan for ARV drugs was developed in 2007 and implemented by the MOHSS, the USG and the Global Fund

to consolidate ARV procurement through the MOHSS Central Medical Stores (CMS). Currently, 93% of the drugs procured with

PEPFAR funds are FDA-approved generics and 7% are FDA-approved branded products. Funds from MOHSS and other donors

will continue to be used to procure non-FDA-approved products.

In 2008, the MOHSS committed to absorbing costs of ARVs previously paid for through the Global Fund and further indicated the

goal of absorbing ARV costs covered by PEPFAR by 2012. This commitment has been documented in the Partnership Compact

for Namibia currently under development.

In FY2009 COP, MOHSS will receive approximately $1.2 million from the USG for ARV drug procurement for FDA-approved

products through the CMS. USG Namibia anticipates an additional $2.57 million Partnership Compact supplement upon

completion of its Compact with Namibia during calendar year 2009. This additional funding will supplement the $1.2 million

currently requested in FY2009 COP. In keeping with MOHSS plan to absorb ARV costs, the total dollar amount of USG support

for direct ARV procurement will decline for the first time since PEPFAR began, from $5.1 million in FY2008 COP to $3.7 million in

FY2009 COP.

USG funds for ARV drug procurement in FY2009 COP will strongly leverage the resources of the MOHSS and the Global Fund,

which funds the bulk of ARV procurement, and the Clinton Foundation, which supports pediatric and second line treatment

commodities.

The supply chain for ARVs and related drugs works well and cost-effectively in Namibia, with a state-of-the-art pharmacy

information system and inventory practices that have virtually eliminated ARV stock-outs. (Please note that SCMS support for

further refining and improving pharmaceutical supply chain management is now described in the OHSS section of the COP. This

support had been funded in the ARV Drugs program area in past COPs.)

Table 3.3.15:

Funding for Strategic Information (HVSI): $40,000

NEW/REPLACEMENT NARRATIVE

IntraHealth (IH) will support all its sub-partners in the use of information for effective program management.

This will be done through improving and harmonizing data collection tools; ensuring data coordination, data

mining, analysis, and ultimately dissemination; and using evidence-based program planning and

improvement. The following are some of activities in different program areas.

The main activities included in this program area will include:

1. Electronic Patient Management System Support:

1.a. IH will continue its support to both the MoHSS and FBH sites through technical assistance in updating

the created system whenever needed.

1.b. The support is mainly central and managed by the chief of party, the newly recruited M&E officer and

the HRIS/informatics technical advisor.

1.c. Continue the maintenance and support of the software through troubleshooting solving activities and

training of MoHSS IT staff, TOT training and FBH staff. This training will involve newly recruited staff and

Data Clerk as well as refreshing training for currently trained staff.

1.d. Support of the IMAI sites whenever requested by the MoHSS and FBHs to ensure proper roll out of the

software beyond the district hospitals whenever requested.

2. VCT software Support:

2.a. IH will continue the activities started in COP07 (creation of the software) and will build on activities

proposed in COP08 concerning the roll out of the VCT software to both integrated VCT and standalone

sites.

2.b. Training of staff and updating the system as needed.

3. M&E Staff training:

3.a. In order to strengthen implementing partners' SI capability, IH will support the training of 30 staff

members from operational levels on M&E through workshops organized with the help of local and regional

consultants in collaboration with RM&E and other USG partners. This will aim at ensuring capacity building

of the partners for a sustainable monitoring system and routine evaluation activities with special emphasis

on data quality, analysis, and use.

3.b. Regional M&E workshop in Pretoria to enroll one senior staff to attend this workshop.

3.c. Regular and periodic (at least quarterly) data quality assessment activities for data auditing.

4. Mystery Clients:

4.a. IH will train a 4-5 mystery clients per region to serve the assessment of client satisfaction and service

quality in different services outlets for its partners' organization mainly on VCT. This will include daily

subsistence allowances, traveling, accommodation, etc as costs for the mystery clients' services.

4.b. IH will use local expert to help in analysis of mystery clients reports.

5. Focus group discussions: As part of quality assessment services for VCT sites, IH will support and

strengthen focus group discussions aiming to improve programmatic decision-making. Suggestion box may

be added as a tool for the same aims. IH staff are active members of the national M&E technical working

group committee and as such will continue to support the strengthening of this committee which in turn

supports the activities of the MOHSS Response M&E division. One of the major activities is the National

multi-sectoral monitoring and evaluation of HIV/AIDS program. Working towards its full implementation will

ensure that Namibia follows the "three ones" principles of UNAIDS. Finally, IH will work with the MOHSS

Research unit, the RM&E subdivision, and other USG partners to revive the national research agenda and

ensure the wealth of data gathered during the past PEPFAR implementation years can be systematically

and rigorously investigated to produce information for planning and decision making based on Namibian

evidence. Community meetings will be fostered to disseminate in layman language critical information

pertaining to the different program areas in order to increase community ownership and involvement.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16137

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16137 7458.08 U.S. Agency for IntraHealth 7361 3078.08 The Capacity $42,624

International International, Inc Project

Development

7458 7458.07 U.S. Agency for IntraHealth 4406 3078.07 The Capacity $143,287

International International, Inc Project

Development

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $20,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.17:

Funding for Health Systems Strengthening (OHSS): $400,000

NEW/REPLACEMENT NARRATIVE

IntraHealth/Namibia, the Capacity is expecting as a result of its COP FY 2006 to 08 capacity building

process to transition to direct funding two sub-grantee partners: Catholic Health Services (CHS) and

Lifeline/Childline (LL/CL) in COP FY 2009. Pending results of the required pre-award survey (responsibility

determination), including a financial/organizational capacity evaluation and availability of FY09 funding, i.e.,

continuing resolution (CR), these 2 organizations may initially have to enter into a ‘Leader with Associates

Award' under IntraHealth and move to direct funding when they meet all eligibility requirements under

USAID's Acquisition and Assistance regulations. This process will ensure the continuity of program

activities. The direct funding mechanism will replace the Associates Award and be implemented as soon as

the 2 organizations are deemed eligible and are approved by the Pretoria USAID Regional Contracting

office.

During COP FY 2006 and COP FY 2007, IntraHealth/Capacity Project (IH) partnered with the MoHSS

stakeholder leadership group (SLG) to strengthen existing human resource information systems (HRIS).

Working with a comprehensive SLG covering all users and producers of Human Resource for Health (HRH)

data has helped ensure ownership of system strengthening efforts. Working together, the SLG agreed on

implementation goals including establishment of a charter to define the group's mission, primary roles and

responsibilities and decision making processes as well as development of data sharing agreements among

and between HRH data managers. In COP FY 2008 and COP FY 2009, IH will continue to build on the

successes as well as formalize the remaining activities as planned with SLG. IH will focus specifically on: (i)

developing and refining the data collection and reporting tools necessary to provide essential indicators as

defined by the SLG; (ii) supporting infrastructure improvements where HRH data are collected and

processed; (iii) improving links between MoHSS HRIS systems and the existing Office of Prime Minister

(OPM) system; (iv) providing training to better assist the data collection and analysis and improved

infrastructure; (v) establishing automated interfaces enabling the sharing of common information generated

between the MoHSS and key stakeholders such as NAMAF, CHS, Health Professions Council and others;

and (vi) complete the coverage of the networking started in COP FY 2007 and COP FY 2009.

With work in COP FY 2007 heavily focused on strengthening central level systems, we propose to work with

the SLG to link the private and public sector systems and to focus on expanding the access to and use of

data at the district level in COP FY 2008 and COP FY 2009. For information to reach the MoHSS in a timely

manner and in order to move to a fully computerized HRIS, the regions require computers, reliable internet

connectivity, and basic data entry and analysis training. In COP FY 2008, IH would have hosted a regional

(SADC) data collection and analysis training conference for IntraHealth Country Offices. In COP FY 2009,

IH plans to host a local Namibian Data Collection and analysis training conference for the MoHSS and its

stakeholders.

To ensure sustainability, IH will continue training on data quality as well as the effective use of information in

influencing policy and management decisions. Training on data and information use not only supports the

utility and continued strength of HRIS systems but also provides support for many key cross-cutting areas

including identifying gender issues, looking for incentive and retention trends and examining distribution of

staff with specific areas of specialty.

During COP FY 2007, IH supported Life Line/Child Line (LL/CL) by creating software that captures training

sessions, trained staff, facilitators, participants' scores, language and region of service. During COP FY

2008 and COP FY 2009, IH will continue the support and maintenance, as well as training of more staff, to

manage the database.

During COP FY 2007, IH assessed the internal operations and management practices of three partner

organizations (CHS, LMS and LL/CL). This assessment focused on the HRM and supervision practices in

particular and identified a number of weaknesses that were undermining the performance and quality

service delivery. In COP FY 2008 and COP FY 2009, IH will continue to strengthen the HRM processes

within all partner organizations, particularly in the areas of supervision, and policies and practices to support

staff retention, motivation and development.

The Namibian HIV Clinicians Society (HCS) has been a key partner in training private and public health

care providers and has become one of the main actors in promoting quality HIV care in Namibian's private

sector. The ability of the Society will be further strengthened to respond to the need for continuous

professional development through regional branches. With the assistance from IH, the HIV Clinicians'

Society will organize professional development seminars, meetings and case discussions for at least 120

participants throughout the country, including private and state practitioners and pharmacists. The Society

will facilitate the dissemination of scientific information and lessons learned to its members. For this

purpose, IH will continue to support the capacity of HCS to organize training sessions and seminars, and

facilitate networking among clinicians. IH will support HCS by continuing support and training of financial

and administrative staff seconded to their office.

On strategic planning for PEPFAR indicators, provision of palliative care other than clinical palliative care

will be requested to report such activity. FBHs provide facility-based clinical palliative care as well

prevention palliative care. To expand the services, IH would have performed the KAP for spiritual care

training needs and trained 12 clergy on HIV related issues and link these skilled clergy to the ART sites

during COP FY 2008. In COP FY 2009, FBHs will commence offering spiritual care to their HIV patients and

families.

IH will continue supporting its local partners on managerial, financial and administrative capacity through

training of their staff. During COP FY 2009, IH will train 36 staff from the 10 different organizations/partners

in collaboration with PACT as some of the IH partners are also PACT partners.

With CP staff actively involved in the National Male Circumcision task force, the drive towards full scale up

of safe MC as part of a comprehensive prevention package within the 6 FBFs by COP FY 2008 will be

Activity Narrative: achieved through advocacy work including media response, education, information (evening lectures) and

assist the MoHSS in finalizing the policy guideline and action framework. These activities will be continued

during COP FY 2009.

The completion of the situational analysis has provided substance to the action framework for service

delivery of MC in selected pilot sites to be started in COP FY 2008 and continued in COP FY 2009. CP will

collaborate with MoHSS, other USG partners, UNAIDS and WHO in the task force in designing and

providing a national training program on MC SOP in line with WHO/UNAIDS/JHPIEGO Technical Manual.

CP and its partners will ensure the performance improvement and the quality of services will be of high

standard through continuous supervisory and support visits and reports from trained staff and their

organizations.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16139

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16139 4738.08 U.S. Agency for IntraHealth 7361 3078.08 The Capacity $500,000

International International, Inc Project

Development

7407 4738.07 U.S. Agency for IntraHealth 4406 3078.07 The Capacity $282,151

International International, Inc Project

Development

4738 4738.06 U.S. Agency for IntraHealth 3078 3078.06 The Capacity $35,244

International International, Inc Project

Development

Emphasis Areas

Gender

* Addressing male norms and behaviors

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $155,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.18:

Subpartners Total: $6,587,822
Catholic Health Services: $2,184,172
LifeLine International: $1,533,702
Lutheran Medical Services: $1,390,002
Anglican Medical Services: $156,247
Evangelical Lutheran Church in Nambia (Various Dioceses): $204,269
Democratic Resettlement Community Project: $185,468
Walvis Bay Multi Purpose Center: $213,738
International Federation of Red Cross and Red Crescent Societies: $127,270
Humana People to People: $171,874
Catholic AIDS Action: $421,080
Cross Cutting Budget Categories and Known Amounts Total: $1,245,076
Human Resources for Health $141,115
Food and Nutrition: Commodities $40,000
Human Resources for Health $25,228
Human Resources for Health $114,500
Human Resources for Health $18,500
Human Resources for Health $48,418
Food and Nutrition: Policy, Tools, and Service Delivery $6,000
Human Resources for Health $143,096
Human Resources for Health $8,545
Human Resources for Health $26,140
Human Resources for Health $5,234
Human Resources for Health $273,800
Human Resources for Health $219,500
Human Resources for Health $20,000
Human Resources for Health $155,000