Namibia Fiscal Year 2008 Country PEPFAR Operational Plan (COP)

NAMIBIA

Project Title: Namibia Fiscal Year 2008 Country PEPFAR Operational Plan (COP)

Budget Summary:

	Field Programs Funding by Account						Central Programs
	Notified November 2007			Notified February 2008			Notified as of February 2008	Allocations to Date
Implementing Agency	GAP	GHCS - State	Subtotal: Field Programs Funding	GAP	GHCS - State	Subtotal: Field Programs Funding	Subtotal: GHCS Central Programs	Grand Total:  Field & Central Funding
DOD	-	-	-	-	2,665,000	2,665,000	-	2,665,000
DOL	-	-	-	-	-	-	-	-
HHS	-	5,652,258	5,652,258	1,500,000	44,547,259	46,047,259	1,700,000	53,399,517
Peace Corps	-	-	-	-	1,205,700	1,205,700		1,205,700
State	-	-	-	-	2,425,000	2,425,000		2,425,000
USAID	-	1,639,000	1,639,000	-	44,238,758	44,238,758	3,164,477	49,042,235
TOTAL	-	7,291,258	7,291,258	1,500,000	95,081,717	96,581,717	4,864,477	108,737,452

HIV/AIDS Epidemic in Namibia:
Adults (aged 15-49) HIV Prevalence Rate: 19.6% (UNAIDS, 2006)
Estimated number of People Living with HIV: 230,000 (UNAIDS, 2006)
Estimated number of Orphans due to AIDS: 85,000 (UNAIDS, 2006)

Country Results and Projections to Achieve 2-7-10 Goals:

Namibia	Total # Individuals Receiving Care and Support	Total # Individuals Receiving ART
End of FY 2004*	96,900	4,000
End of FY 2005**	146,300	14,300
End of FY 2006***	142,700	26,300
End of FY 2007****	163,900	43,700
End of FY 2008*****	150,998	46,530
End of FY 2009*****	201,085	64,240

^* "Engendering Bold Leadership: The President’s Emergency Plan for AIDS Relief.” First Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U. S. Department of State, March 2005.
^** “Action Today, a Foundation for Tomorrow: The President’s Emergency Plan for AIDS Relief.” Second Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U. S. Department of State, February 2006.
^*** "The Power of Partnerships: The President’s Emergency Plan for AIDS Relief.” Third Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U.S. Department of State, February 2007.
^**** "The Power of Partnerships: The President's Emergency Plan for AIDS Relief." 2008 Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U.S. Department of State, January 2008.
^***** Projections from FY 2008 Country Operational Plan

Program Description/Country Context:

Namibia has a severe, generalized HIV epidemic with an estimated 230,000 HIV-infected individuals. Namibia’s HIV prevalence of 19.9% in pregnant women is one of the highest in the world. HIV transmission is largely through heterosexual contact and/or through mother-to-child transmission. Social, economic and cultural factors such as population migrations, disempowered women, alcohol, stigma, multiple concurrent partners, and lack of male circumcision help drive the epidemic.

The tuberculosis (TB) case rate of 765 cases per 100,000 in Namibia is one of the highest in the world (MOHSS 2006), with HIV co-infection estimated at 67% and an increasing number of MDR cases. TB continues to be the leading cause of death for people with HIV/AIDS, even with the availability of antiretroviral therapy. Additionally, Namibia has the world’s highest rate of unequal income distribution (Gini Coefficient of 70.9), high levels of poverty and food insecurity, and a lack of economic opportunity. Building human capacity, increasing the quality of services, and planning sustainable response strategies will be important considerations in FY 2008.

The following programmatic areas will be included in FY 2008 to mitigate the impact of the epidemic in Namibia:

Prevention: $25,461,991 ($21,932,960 Field; $3,529,031 Central) (28.9 of prevention, care and treatment budget)

Prevention activities will continue to focus on increasing abstinence and delayed sexual debut, faithfulness and partner reduction, and consistent condom use when appropriate. New and scaled-up programs this year will address harmful male norms; Prevention with Positives; the role of alcohol abuse in HIV transmission and treatment adherence; integrating prevention interventions into existing structures such as the schools, the military and facility-based care; and addressing risk factors contributing to cross-generational and transactional sex. In recognizing the need to prevent new infections, strategies have been developed to determine the local and national drivers of Namibia’s epidemic through incidence testing, a data triangulation exercise, and work with the Ministry of Health and Social Services (MOHSS) and UNAIDS to complete a national prevention assessment. Based on these analyses, appropriate and targeted behavior change interventions will be refocused. Interventions will include a range of behavior change messages targeted at populations engaged in high risk behaviors and those traditionally underserved, and will be developed with significant input from HIV-positive individuals and service consumers. Programs developed to target specifically populations engaged in high risk behaviors will be a key prevention strategy, as will population-based, door-to-door educational programs that will continue to be expanded in coordination with the Government of Namibia (GON) and the Global Fund to Fight HIV/AIDS, TB, and Malaria (Global Fund).

Currently the national prevention of mother-to-child transmission (PMTCT) guidelines are being reviewed and updated and should be published by the end of calendar year 2007. The antiretroviral (ARV) prophylaxis regimen for HIV-positive mothers will be strengthened to short-course AZT beginning at 28 weeks of pregnancy, plus a seven-day course of AZT/3TC to the mothers at the onset of labor and to the baby for seven days postpartum, in addition to single dose Nevirapine. During FY 2008 the USG will continue to provide rapid test kits, ARV drugs, laboratory testing, personnel, training, management support and technical assistance to support the medical facilities providing PMTCT.

Care: $30,381,218 ($29,045,772 Field; $1,335,446 Central) (34.4% of prevention, care and treatment budget)

Care activities will continue to focus on supporting Namibia’s policy shift to the Integrated Management of Adult Illness (IMAI) practices; increasing counseling and testing (CT) services using rapid test technology; ensuring OVC are identified and provided with a full package of quality services; expanding access to facility-based and community-based palliative care; and increasing linkages between TB and HIV testing and care services. Partners will strategically rollout CT services based on local assessments and government guidance. Health facilities will promote routine provider-initiated CT for HIV to improve timely linkage of people living with HIV/AIDS (PLWHA) to prevention, care, and treatment services. CT services in health facilities will expand in FY 2008, through training of additional clinic-based community counselors. In These additional counselors, supported through PEPFAR funds, will allow MOHSS’ initial foray into providing CT in outreach and correctional settings for the first time.

All partners will continue to strengthen linkages between care, CT, and referral services. To enhance the quality of services delivered and to abide by recent guidance on palliative care, the PEPFAR team plans to work closely with partners in community-based settings to implement basic standards of care and quality assurance, to integrate palliative care into a national standard for community home-based care, and to strengthen bi-directional referral systems with facilities. Health care providers will focus on improving the quality of palliative care and anti-retroviral therapy (ART), including the preventive care package. TB activities will focus on the integration of HIV/TB services by increasing HIV testing of TB patients and TB testing of ART patients, and by improving bi-directional linkages to HIV/TB care and treatment. Other TB/HIV activities will help improve timely detection and treatment of TB by strengthening linkages between laboratories and health facilities, and by increasing DOTS service points to improve adherence to TB treatment.

With a population of approximately 189,396 OVC in Namibia, PEPFAR support will continue to focus on identifying OVC and delivering a minimum package of quality services to them. Building on work completed in FY 2007 defining the minimum standards of quality OVC services, the PEPFAR team will work with partners in FY 2008 to implement and evaluate these standards of service. Income-generating activities for OVC and their care providers will be expanded and evaluated as a joint economic development and prevention intervention, and support for the education of OVC will increase in coverage and services.

Treatment: $32,362,063 ($32,362,063 Field; $0 Central) (36.7% of prevention, care and treatment budget)

In FY 2008, PEPFAR support will focus on treatment activities that decentralize services, improve quality, support procurement and supply chain management of ARV drugs and related commodities, and shift tasks in order to continue to expand coverage to more rural sites, build human capacity and deliver quality services. Particular emphasis will be placed on building laboratory capacity and quality assurance, including timeliness of specimen transport and electronic communication of results between laboratories and facilities. Recruitment of contracted doctors, nurses, and pharmacists will be paired with expansion of scholarships for training of new professionals and human resource planners. In addition, a Masters in Public Health program will be developed with concentrations in general management and finance, policy development, monitoring and evaluation, and nutrition. The USG will continue to provide technical advisors who work alongside government and community counterparts to build capacity in program management, monitoring and evaluation, health information systems, palliative care, treatment, prevention, tuberculosis, laboratory services and technical writing.

Other Costs: $20,532,180

In FY 2008, technical and financial support will expand and strengthen the USG-supported national health management information systems (HMIS) to make them more relevant to service providers and policy makers while enhancing a system that is sustainable in the presence of support from PEPFAR and other donors. HIV surveillance for transmission of drug-resistant HIV in the general population and multi-drug resistant TB (MDR-TB) will be expanded in FY 2008. With the consensus of the MOHSS and in line with the host government’s priorities, the USG will help build capacity for evaluations of public health evaluation programs in order to document impact at the population level.

The USG will continue to support the MOHSS in its monitoring and evaluation of the national HIV/AIDS response through technical assistance and material support. In FY 2008, the USG and MOHSS are planning a population-based AIDS Indicator Survey (AIS) for the collection of behavioral and sero-status data. In addition to the AIS, the USG Strategic Information team, working with the MOHSS, UNAIDS and the Global Fund, will also undertake a national prevention assessment, a situational assessment of Male Circumcision in Namibia with a costing and impact component, and a Service Provision Assessment.

Programs addressing cross-cutting issues in the government and civil society will continue to provide training on human resource development, organizational capacity building, and community mobilization and advocacy, and education on available benefits. Scholarships for Namibian students will be sustained at a high level in the continuing effort to address Namibia’s severe human resource shortages in medical and allied health professions. The integration of HIV/AIDS into existing pre-service training programs for health care workers and continued use and expansion of digital video conferencing will reduce costs and expand expertise on human resource burdens due to training while expanding the skills of new and existing health care providers. Community Action Forums will help bring HIV into the mainstream and support a full range of HIV/AIDS services at the community level. Government and business partners will initiate and expand workplace HIV/AIDS programs, while national and local HIV/AIDS umbrella organizations for the public and private sectors will be strengthened in order to expand their effectiveness in reaching PLWHA, fighting stigma and bringing HIV/AIDS issues to a broader audience.

Administrative Costs will support both basic program operations, and the technical assistance required to implement and manage FY 2008’s PEPFAR activities carried out by the five USG agencies in Namibia: DOD, DOS, HHS/CDC, Peace Corps and USAID. Operational costs will include personnel, travel, management, and logistics support in-country.

Other Donors, Global Fund Activities, Coordination Mechanisms

The Global Fund is the second largest donor (behind the USG) in the fight against HIV/AIDS, and Namibia is currently utilizing a round two, phase two grant of $47 million. Other development partners include the European Union, the GTZ, and UN agencies, including the WHO, UNAIDS, UNICEF, UNFPA and the UNDP. Global Fund funding supports ART and care services, OVC programs, workplace HIV programs, support for community-based care, TB control, CT, PMTCT-Plus and community outreach services. The USG has been asked to co-chair the UN Partnership Forum which provides an HIV/AIDS partner coordination mechanism among development partners, and has recently become a member of the Global Fund’s Country Coordinating Mechanism.

The USG also sits on the National AIDS Executive Committee (NAEC), chaired by the Deputy Permanent Secretary of MOHSS, which coordinates implementation of HIV/AIDS activities throughout Namibia. The National Multi-Sectoral AIDS Coordinating Committee (NAMACOC), supported by the National AIDS Coordination Program (NACOP) as Secretariat, is responsible for multi-sectoral leadership and coordination. The membership of the committee consists of the Secretaries of all government ministries, major development partners, NGOs, FBOs, trade unions and private sector organizations. The USG team will continue to work with the Namibian government and other development partners to maximize resources, ensure coordination of HIV policies and programs, and to promote sustainability of programs.

Program Contact: Ambassador Denise Mathieu, DCM Eric Benjaminson, and PEPFAR Coordinator Dennis Weeks.

Time Frame: FY 2008 – FY 2009

Approved Funding by Program Area: Namibia