This is a single eligibility follow-on mechanism to replace an expiring Track 1 cooperative agreement with The Blood Transfusion Service of Namibia (NAMBTS). Although this IM is listed as a "TBD partner," NAMBTS will be the only entity eligible for the award. A single eligibility request for proposals (for a five year cooperative agreement) will be issued in November 2009. An award to NAMBTS is expected within the COP10 approval timeframe. This IM will support activities in the HMBL technical area. However, many of the activities will have cross- cutting impacts beyond the prevention of HIV. Specific HIV prevention objectives for the PEPFAR- supported blood safety program include: 1. Maintaining (and reducing) the low HIV prevalence among voluntary, non-remunerated blood donors. In COP09, HIV prevalence among blood donors stood at <.50%. This will be accomplished through 100% screening of all donated blood for HIV, Hepatitis B and C, and syphilis. 2. Doubling the blood donation rate among youth. In COP09, less than 15% of all donations were collected from donors aged 16-25. 3. Linking school-based education programs targeting blood donors to broader HIV prevention and healthy lifestyles messaging delivered in schools. 4. Training clinical staff to reduce unnecessary blood transfusions.

Links to the Partnership Framework (PF) As part of the USG contribution to the PF goal of "enhancing prevention," the USG commits to support NAMBTS as the GRN-authorized partner responsible for the safety and adequacy of the national blood supply. USG commitments in the PF are aligned with the HIV prevention priorities described in Namibia's National Strategic Framework for HIV and AIDS 2010-2015 (NSF). 1. Social and Behavior Change 2. HIV Counselling and Testing (HCT) 3. Prevention of HIV among Most-At-Risk and Vulnerable Groups 4. HIV Prevention Involving PLWHA 5. Medical Male Circumcision 6. PMTCT 7. Post-Exposure Prophylaxis 8. Condom Social Marketing and Distribution 9. Prevention of Sexually Transmitted Infections 10. Blood Safety

With funding through this new IM, NAMBTS will directly contribute to the Blood Safety objectives and commitments described in the PF documents and in the NSF. As noted above, PEPFAR investments in blood safety will also have a number of cross-cutting benefits, including indirect contributions to HCT and PMTCT by referring blood donors with HIV reactive test results to HCT and PMTCT services. As the sole entity responsible for supplying hospitals and clinics with blood for transfusion, NAMBTS directly contributes to strengthening the broader primary healthcare system. Since a substantial proportion of the nation's blood supply is consumed by children (malaria anemia) and pregnant women (post-partum hemorrhage), PEPFAR investments in blood safety directly contribute to improving maternal and child health outcomes (MCH).

Coverage and Target population The activities supported through this mechanism are national in scope. NAMBTS supplies screened blood and blood products to 41 hospitals and clinics in all of Namibia's 13 regions. With PEPFAR support, NAMBTS has expanded access to blood transfusion services by pre-positioning Type O (universal donor) blood at facilities that lack cross-matching capacity. In COP10 PEPFAR will support and evaluate this strategy, and support improvements in local cross-matching capacity where cost effective.

Health Systems Strengthening The blood safety program also invests in capital infrastructure at the facility level (e.g., ward-based cold chain) and in training for clinicians in the appropriate use of blood. NAMBTS also trains laboratory technicians in the proper handling of blood and the production of quality-assured blood products (e.g., packed red cells, platelets). In COP10, NAMBTS will work with CDC and the MOHSS to create training internship opportunities for laboratory technician students at the Polytechnic of Namibia.

Cross-Cutting Programs and Key Issues Access to safe blood can improve maternal and child health outcomes. In COP10, CDC and NAMBTS will work with the MOHSS Directorate for Primary Health Care to track blood utilization patterns and measure the impact of safe blood on clinical outcomes. This evaluation will also look at blood utilization among ART patients. Investments in laboratory technician training opportunities will also build Human Resources for Health.

Cost Efficiencies Over Time An innovative cost-recovery system currently provides a sustainable source of funding for NAMBTS. Through this system, NAMBTS is reimbursed by public and private insurance programs. NAMBTS is also engaged in negotiations with private sector pharmaceutical companies in South Africa regarding the potential sale of plasma. Supporting Namibia as an exporter of plasma to the South African and, potentially, global, plasma markets would substantially enhance NAMBTS's ability to sustain itself over

the long-term. PEPFAR will continue to support quality assured laboratory practices during the accreditation process with the South African Bureau of Standards.

Monitoring and Evaluation Plans NAMBTS will maintain, expand and align the M&E system developed under the Track 1 cooperative agreement. NAMBTS will submit bi-annual reports on all of its indicators. These reports will indicate any changes to the M&E system during the reporting period. As noted above, an impact evaluation will be conducted on the clinical use of blood.

This is a continuing activity from COP09. Activities implemented by the Blood Transfusion Service of Namibia (NAMBTS) in COP10 will focus on the following four areas:

1) Blood Collection 2) Blood screening 3) Blood utilization

4) Policy and Sustainability

NAMBTS has been a PEPFAR Track 1 partner since 2004. In COP 2010, the management of the CDC cooperative agreement with NAMBTS will transition to the CDC country office from CDC headquarters. This transition is part of a broader expansion of the former Track 1 blood safety program beyond the original 14 Focus countries. As part of this expansion, COP10 blood safety budgets for the former Focus countries were reduced and redistributed to support expanded blood safety investments in non-Focus countries. In Namibia, this reduction and redistribution strategy resulted in a 30% budget cut for NAMBTS. Within this context, NAMBTS will continue to implement the comprehensive blood safety program described in prior years. Specific activities will include:

1) Blood collection. NAMBTS will work to Retain current blood donors, expand recruitment activities to schools, and conduct ongoing surveillance of transfusion transmissible infections (TTI) among donors to identify lowest risk sub-groups 2) Blood screening. NAMBTS will maintain a contract with the South African National Blood Service (SANBS) for all infectious disease screening (including nucleic acid screening for HIV). This arrangement is subject to a bi-annual sustainability review, which is scheduled to occur in March 2010. If necessary, based on the findings of that review, this narrative will be updated to reflect any changes in the NAMBTS screening policy. 3) Blood utilization. NAMBTS will continue training for clinicians in the rational clinical use of blood. This training is designed to minimize wastage, reduce patients' risk of transfusion-associated reactions, and preserve scarce stocks of blood. Within this activity category, NAMBTS will also work with the MOHSS Department of Clinical Services and NIP to expand and strengthen the national network of blood banks and compatibility testing laboratories, with an emphasis on supervision and quality assurance. Other activities will include: Support to MOHSS to draft legislation to regulate blood transfusion nationwide; conduct assessments to define the level of transfusion services to be provided at Namibian hospitals; procure appropriate reagents and equipment for all hospital blood banks; train hospital blood bank staff on cross-matching, quality, and cold chain management; continue to advocate for implementation of a national hemovigilance program; strengthen hospital therapeutic/transfusion committees; conduct blood bank and hospital audits to ensure conformity with best practices; expand access to cross-matching services to northern Namibia, specifically in Rundu and Oshakati. a. Policy and Sustainability. NAMBTS will continue to participate with the MOHSS and relevant legislative branch offices to advocate for the passage of a new national Blood Bill. Finalization and passage of this bill has been pending since 2006. b. Advocate for the finalization and passage of the new national Blood Law. Passage of the Blood Bill will allow implementation of the National Blood Authority. Other activities will include: Defining criteria for the import and export of blood and blood products, and continuing negotiations on the potential sale of plasma to a commercial pharmaceutical firm;

implementing a quality management system for the entire blood program