Ministry of Health and Social Services

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1 Republic of Namibia Ministry of Health and Social Services NATIONAL AIDS COORDINATION PROGRAMME Mid-Term Review THE THIRD MEDIUM TERM PLAN ON HIV/AIDS Review Report 1 st - 30 th June 2007

2 TABLE OF CONTENTS Acknowledgement 4 List of abbreviations 5 Objectives of the review and methodology 7 COMPONENT 1: ENABLING ENVIRONMENT FOR EFFECTIVE HIV/AIDS RESPONSE 12 Sub-component 1.1 Sustained Leadership commitment 13 Sub-component 1.2 Greater Involvement of PLHWA 15 Sub-component 1.3 Policy and Law Reform 17 Sub Component 1.4 Interventions to reduce stigma and discrimination 18 COMPONENT 2: PREVENTION 19 Sub component 2.1 Strengthen Capacity to Deliver HIV/AIDS Prevention Programs 20 Sub component Target behaviour change interventions for vulnerable populations 23 Sub component Prevention of HIV Transmission in Health Care Settings 27 Sub component 2.3 Behaviour Change Interventions for young people 29 Sub component Social Mobilization and Awareness 34 Sub-component Workplace Programmes 37 Sub-component Expand Condom Provision 39 Sub-component: STI Management 42 Sub-component Voluntary Counselling and Testing 44 Sub-component Safety of Blood Transfusion Products 46 Sub component 2.5 Addressing vulnerability based on gender inequality, violence and alcohol abuse 48 COMPONENT 3: ACCESS TO TREATMENT CARE AND SUPPORT SERVICES 51 Sub-component 3.1 Capacity Development for the Health Sector 53 Sub-component Laboratory services for HIV/AIDS management 56 Sub-component Procurement and Supplies 58 Sub-component Prevention of Mother To Child Transmission of HIV 61 (PMTCT) Sub-component Management of Opportunistic Infections 64 Sub-component Organization and integration of services, integrated 65 TB/HIV and Opportunistic infections Sub-component Provision of HAART 68 Sub-component Home Based Care 70 Sub-component Access and Use of Services 73 COMPONENT 4: IMPACT MITIGATION SERVICES 77 2

3 Sub-component Developing Capacity for Local Responses 78 Sub-component Involvement and capacity building of PLWHA 82 Sub-component 4.2 Services for OVC & PLWHA 84 Sub-component 4.3 Poverty, food security, nutrition and housing 87 COMPONENT 5: INTEGRATED AND COORDINATED PROGRAMME MANAGEMENT AT ALL LEVELS 94 Sub-component 5.1 Developing HIV/AIDS Management Capacity 96 Sub-component 5.2 Management and Coordination 100 Sub-component 5.3 Monitoring and Evaluation 122 Sub-component 5.4 Surveillance and Operational Research 124 Annexes People Met by the Review Team Reference Documents 3

4 Acknowledgement The core team wishes to acknowledge and thank the Namibian Government, especially staff at the Ministry of Health and Social Services for their active support of the review process. Special thanks must be reserved for Dr. K. Shangula, Dr. Forster, Mrs Ella Shihepo and Mr Abner Xoagub for their assistance and support of the mid-term review team. We would also like to thank all the partners and stakeholders who agreed to see us - often on short notice to enable the review to be comprehensive. We are also greatly indebted to the regional aids co-ordinators, RACOC s, authorities and implementing partners in the 13 regions for graciously receiving our teams, organising meetings on short notice and accompanying us to see their activities and services and to meetings with PLWHA and clients. Finally we would like to thank Ms Jeany Auala, Ms Melodi Orr and Mr George Eiseb whose diligent work as a secretariat made the review possible within the relatively short time. Ms Jacqueline Therkelsen also deserves our gratitude for working tirelessly to edit the entire project in a seemingly impossibly short time. Mid-Term Review Team Members: Prof Nana K. Poku Review Team Leader Dr Lucie Blok - Cluster Leader Treatment Care and Support Ms Pebetse Maleka - Cluster Leader Enabling Environment Mrs Pam Baatsen - Cluster Leader Prevention Dr Munirat Ogunlayi - Cluster Leader Impact Mitigation Mr Jim Myers - Cluster Leader Programme Management Dr Christine Chakanyuka, Ms Rosebell W. Chege, Prof David Hotchkiss, Dr Eddie Limambala, Mr Gerard van Mourik, Mrs Agnes Mugala Aongola, Mr Takondwa Mwase, Mrs Namposya Nampanya Serpell, Ms Mikaella Rejbrand, Ms Asunta Wagura. Prof Anthony Barnett Scenarios Facilitator Prof Pieter Fourie - Scenarios Facilitator Dr Francoise Jenniskens - Scenarios Facilitator 4

5 LIST OF ABBREVIATIONS ACT ADT AHA AIDS ALU ANC ART ARV BCC BCI BMI CAA CACOC CAFO CBO CDC CDC CHW CLAAHA CMS CPT CSO DACOC DHS DOTS DSP ELCIN FAO FP GF GIPA HAART HBC HIV HR HRD IGA IMAI IPC JFFLS LAC MAPP MCH MDR-TB MFMC MoAWF MoE MoGECW MoHSS MoJ MoL MoRLG AIDS Care Trust ART Dispensing Tools Africa Huminitarian Action Acquired Immuno-deficiency syndrome AIDS Legal Unit Anti Natal Care Antiretroviral Therapy Antiretroviral drug Behavioural Change Communication Beharioural Change Intervention Body Mass Index Catholic Aids Action Constituency AIDS Coordinating Committee Church Alliance for Orphans Community Based Organisation Center for Disease Control Communicable Disease Clinic Community Health Worker Community Led Action against HIV/AIDS Central Medical Stores Cotrimoxazole Prophylactic Treatment Civil Society Organization District Coordinating Committee Demographic and Health Survey Directly Observed Treatment Short course Directorate of Special Programmes Evangelican Lutheran Church in Namibia Family Planning Global Fund Greater Involvement People living with HIV/AIDS Highly Active Antiretroviral Treatment Home Based Care Human Immune deficiency Virus Human resources Human Resource Development Income Generating Activity Interated Mangaement of Adult Illnesses Inter-Personal Communication Junior Farmer Field Life Schools Legal Assitance Centre Men as Partners Programme Maternal and Child Health Multi-Drug Resistant Tuberculosis My Future is My Choice Ministry of Agriculture, Water and Fisheries Ministry of Education Ministry of Gender Equality and Child Welfare Ministry of Health and Social Services Ministry of Justice Ministry of Labour Ministry of Regional and Local Government 5

6 MSM MTP III MTR NABCO NAC NAEC NANASO NAPPA NaSoMa NCC NDHS NEPRU NFSNC NFSNS NGO NGO NHTC NPC NRCS OIs PCR PEP PEPFAR PHC PLHA PLWAS PMTCT RAC RACOC RACOC RH RPM SMA SdNVP SOP STI TB TCE VCT WFP WOH WPP XDR-TB Male having Sex with Male Third Medium Term Plan on HIV/AIDS Med-Term Review National Business Coalition National AIDS Committee National AIDS Executive Committee Namibia Network of AIDS Service Organisations Namibian Planned Parenthood Association National Social Marketing Programme Namibian Council of Churches Namibian Demographic Health Survey National Economic Policy Research Unit Namibian Food Security and Nutrition Council Namibia Food Security and Nutrition Secretariat Non Government Organisation/s Non Governmental Organisation National Health Training Centre National Planning Committee Namibian Red Cross Society Opportunistic Infections Polimerase Chain Reaction test Post Exposure Prophylaxis Presidents Initiative for AIDS Relief Primary Health Care People living with HIV and AIDS People living with HIV and AIDS Prevention of Mother To Child Transmission Regional AIDS Coordinator Regional AIDS Coordinating Committee Regional Aids Co-ordinating Council Reproductive Health Rational Pharmaceutical Management Social Marketing Association Stat dose of Nevirapine Standard Operating Procedures Sexually Transmitted Infections Tuberculosis Total Control against the Epidemic Voluntary Counselling and Testing World Food Programme Windows of Hope Work Place programme Extreem Drug Resistant Tuberculosis 6

7 Objectives of the review and methodology On reaching the third year of implementing the Third Medium Term Plan (MTP III) on HIV/AIDS, the National AIDS Executive Committee (NAEC) in Namibia commissioned an external review of the implementation of this plan. The purpose of this external medium term review (MTR) is to provide Namibia s National AIDS Committee (NAC) with an independent view of the current status of implementation of the Third Medium Term Plan and to provide policy recommendations on how to strengthen the national efforts to combat the HIV/AIDS epidemic. More specifically the MTR is requested to evaluate effectiveness, efficiency, equity, relevance, inclusiveness and sustainability of the interventions under the five MTP III components and to provide guidance for a systematic prioritisation that will further increase the effectiveness and efficiency of the response. Given the fast roll-out of AIDS related services, Namibia recognised the need to increase scale up, but also to adapt its approaches in order to reach universal access targets and to obtain recommendations on ways to target services towards vulnerable groups. The review is therefore requested to look into approaches towards decentralized regional and local response and to assess the implementation capacity required and recommend ways to safeguard sustainability. Furthermore the MTR is asked to look into the coordination mechanisms and means of ensuring political commitment for the multisectoral response. To assess the involvement of people living with HIV/AIDS (PLWHA), and of the impact of the response on those affected by HIV/AIDS, vulnerable groups, communities and civil society. To review the roles, responsibilities, performance and impact with regard to leadership, guidance, coordination and management, implementation, monitoring and evaluation of the main stakeholders. To assess the sector response by various line ministries including mainstreaming and work place policies. To provide recommendations to increase and strengthen the regional and local response with focus on political commitment, resource allocation, human resource development and sustainability. To review the existing HIV/AIDS coordinating bodies, structures and systems on effectiveness, relevance, representation and provide recommendations with respect to strengthening the leadership and translation of commitment into action. To assess whether strategies and interventions are inclusive, complementary and do effectively, include improved access for vulnerable groups. To provide recommendations on the HIV/AIDS service integration into the overall health systems. To review commitments and allocations of the public sector, private sector, civil society and of the external assistance of development partners and provide recommendations towards a more efficient allocation and use of resources with focus on equity and sustainability. To make recommendations where reorganization, priority setting and (re)allocation of resources must take place. To recommend actions to be taken in order to ensure the attainment of the universal access targets. 7

8 Methodology The review was structured in five phases as shown in Figure1.0. Figure 1.0: review methodology During the inception phase which started on the 1 st June and lasted approximately five days the review team was briefed by members of the directorate of special programmes within the Ministry of Health and Social Services (MoHSS) and received background documents for review. In the course of the first week the five core team members were joined by 11 additional team members assigned by the various MTP III partners. All team members were assigned specific tasks and were allocated to five clusters representing the five components of MTP III, each with a cluster leader. Team members developed tools and interview guidelines for their assigned topic areas, which were subsequently checked for completeness and consistency under guidance of the cluster leaders. The review itself consisted of a desk review of all relevant and obtainable documents and interviews with stakeholders and MTP III partners to collect factual information, views and opinions. People interviewed included highest level Namibian policy makers, authorities, bilateral and multilateral partners and donors. Consultations were held with programme managers and technical staff of the different ministries and implementing organisations, including non governmental organisations (NGOs), faith based organisations (FBOs), and private companies, and partnership forums. Furthermore, interviews were held with PLWHA, support groups, volunteer workers and representatives of specific vulnerable groups such as sex workers, gay men and lesbians, and prisoners. One NAEC meeting and a NAC meeting were attended and observed. All 13 regions were visited by four multidisciplinary review teams. During these visits meetings were organised with governors and representatives of local government, with RACOCs, community based organisations (CBOs), PLWHA and support groups, health authorities, social workers, teachers, secondary school students, hospital staff 8

9 and volunteer workers amongst others. Services and projects were visited to obtain first hand information on activities, assess progress and identify challenges faced. Following the phase of interviews, (field) visits and data collection, all consultants prepared draft summary reports on their assigned topic areas. Findings were compared and checked for consistency within the clusters and cross cutting themes were identified. The fourth week of the assignment was used for follow up meetings and interviews to fill gaps and clarify issues where needed. A summary of the main findings regarding progress and identified challenges was prepared for each cluster and for cross cutting themes, in line with the main objectives of the review. The fourth phase of the review consisted of a two day scenario workshop, as an innovative way to identify and highlight driving forces and key actors influencing the course of the epidemic. In a participative forum key decision makers and knowledgeable people identified the main drivers and actors and considered four possible scenarios for the future. These scenarios provide clues for actions and decisions that are likely to influence the future and are therefore built into the recommendations of this review. A full report was compiled by the core team members using the summary reports of the individual consultants and the scenario workshop. All consultants were given an opportunity to comment on the draft report. The team leader in collaboration with the cluster leaders and some consultants summarised the key findings and main recommendations into an executive report, which was subsequently presented during a NAEC and NAC meeting on the 31 st July and 1 st August Table XX: Topics covered by the different members of the review team. Consultant Topics covered Mrs Baatsen P. MSC Prevention capacity development, BCI in general public and youth, social mobilisation, Dr Blok L. Capacity development in the health sector. Organisation and integration of HIV/AIDS services, HIV and tuberculosis, Home based care. Monitoring, evaluation and surveillance Dr Chakanyuka C. HAART, PMTCT, Opportunistic infections, STI s, prevention of transmission in the health sector, safe blood transfusions, Laboratory. Ms Chege R W Gender issues Prof Hotchkiss D. Drugs and supply systems; Awareness, access and use of services. Dr Limambala E. HAART, Opportunistic infections, STI s, PMTCT Ms Maleka Pebetse Enabling environment, policy and legal frameworks, work place programmes Mr Mourik v, G Targeting vulnerable populations, access to prevention and services Mrs Mugala Aongola A Food security, nutrition, poverty reduction Mr Myers J Prevention, condom promotion and social marketing, VCT, BCC, programme management, monitoring and evaluation Mr Mwase Takondwa Resource analysis, costing; resource allocation Mrs Nampanya Serpell N, PhD Financial analysis, costing; resource mobilisation and allocation Dr Ogunlayi M, Impact mitigation, capacity of local and community response, FBO and NGO response. Prof Poku N Team Leader Governance and coordination structures; political commitment; multi sector response Mrs Rejbrand M Support to orphans and vulnerable children, their care takers and PLWHA Ms Wagura Asunta Greater involvement of people living with HIV AIDS (GIPA); capacity of patient support groups; access to services Prof Barnett A Facilitator scenarios building workshop Prof Fourie P Facilitator Scenario building workshop Dr Jenniskens F Co-facilitator Scenario building workshop 9

10 Figure XX: HIV/AIDS MTP III medium term review : task division consultants MTP-III National AIDS Programme Review Team Nana Poku (team leader) Lucie Blok (co-team leader) 1 Enabling Environment for an Effective Response to HIV/AIDS Cluster Leader: Pebetse Maleka 2 Prevention Cluster Leader: Pam Baastsen Team 3 Treatment, Care, & Support Cluster Leader: Lucie Blok Team 4 Impact Mitigation Cluster Leader: Munirat Ogunlayi Team 5 Programme Management Cluster Leader: Jim Myers Team Team Pebetse Maleka Rosebell W. Chege Nana Poku Pam Baatsen Gerard Van Mourik Jim Myers Christine Chakanyuka Rosebell W. Chege Lucie Blok David Hotchkiss Eddie Limbambala Christine Chakanyuka Munirat Ogunlavi Mikaela Rejbrand A. M Mugala-Aongola Asunta Wagura Jim Myers Nana Poku Namposy Nampanya-Serpell Takondwa Lucious Mwase 1.1 Capacity development: Leadership 1.2 PLWHA involvement 1.3 Policy & law reform 1.4 Interventions to to reduce stigma and discrimination Mainstreaming HIV/AIDS (comp 5.2.4) Workplace programmes (comp 2.4.2) Capacity development: prevention Target vulnerable populations Prevention of of transmission in in Health care settings 2.3 Target young people 2.4 Target general population (social mobilization, workplace, condom provision, STI, VCT) 2.5 Interventions to to reduce vulnerability 3.1 Capacity development: Treatment, care and support Laboratory services Procurement and Supplies PMTCT Treatment of of Opportunistic infections Organisation and integration of of services, integrated TB/HIV Provision of of HAART 4.1 Capacity development: Local responses Capacity of of local support groups of of PLWHA 4.2 Services for for OVC, their care takers and PLWHA 4.3 Addressing poverty and Food Security 5.1 Development of of HIV and AIDS management capacity 5.2 Management & coordination Financing HIV / AIDS reponse 5.4 Programme monitoring & evaluation 5.5 Surveillance and operational research Home based care services Source: Review team-leadership Access and use of of services 10

11 Limitations and challenges faced during the review The review was rapid and had to be completed in one month, while the MTP III covers a wide range of policies and interventions and the number of stakeholders and actors is vast. This obviously posed a challenge to the review team to cover all ground. No appointments for interviews had been scheduled prior to the arrival of the consultants, which lead to delays in stakeholder consultations. Furthermore much of the relevant information and up to date studies were not immediately available to the team such as the results of the 2006 DHS, MTP III progress report for the year 2006/2007 and the report on the sentinel HIV surveillance. This also applied to a number of recently drafted implementation guidelines. Until recently, for most intervention areas the regular monitoring focused mainly on input and output indicators. Data on outcome are scarce, such as change in attitude and behaviour, treatment outcomes and defaulting, HIV transmission rates from mother to child, drug sensitivity, correct and consistent condom use etc. This has implications for the possibility to evaluate effectiveness of the interventions and actions and time was too short to implement field studies to obtain additional information. Despite the limitations mentioned the team firmly believes it has been able to make an informed judgement and formulated valid findings based on compiled information, data and field studies by MTP partners combined with observations during field visits and grounded in the broader experience of the team as a whole. Recommendations are made to improve monitoring of effectiveness in the future. The field visits into the regions were limited to one or two days per region, which did not allow visits outside the main cities. The lack of depth of analysis within the regions was, however, partially compensated by the fact that all regions were covered and therefore had a chance to voice their concerns and contribute to the review. Furthermore, insight into the specific challenges of remote places was obtained by interviewing PLWHA, and volunteers and staff of NGOs that work throughout the regions. Another challenge faced by the review team was the size of the team (16 members) and the late announcement and arrival of a number of the added consultants. This resulted in a situation where the definite composition of the team and the division of tasks was known only one week into the review. Team members however have been extremely flexible and to a large extent compensated for the loss of time by quickly picking up on their tasks and fitting themselves into the predefined review framework. Quality assurance and checking of consistency of findings within such a large team is obviously a challenge, but this was dealt with by assigning five cluster leaders with the responsibility to assure coherence and completeness. The team leader assisted by the co-team leader assured smooth implementation of the review process as a whole and compiled the final report. 11

12 Findings and Recommendations COMPONENT 1: ENABLING ENVIRONMENT FOR EFFECTIVE HIV/AIDS RESPONSE Expected outcome: To see to it that people infected and affected with HIV/AIDS enjoy equal rights in a culture of acceptance, openness and compassion. The section on the enabling environment in the MTP III is set out to facilitate the implementation of interventions and activities that lead to the attainment of an environment where the rights of PLWHA are realised and respected. Premised on the prevailing situation of the time, the expected result is that the people infected and affected with HIV/AIDS enjoy equal rights in a culture of acceptance, openness and compassion. The high level activities identified are a) the capacity development of leadership for a sustained leadership commitment to engage in the national response ; b) participation of PLWHA in training and advocacy, and involvement in national decision making bodies amongst others; c) relevant law reform to create a framework to reduce vulnerability to HIV, improve access to prevention and care, and mitigate the impact of HIV/AIDS; and d) appropriate and accessible social mobilisation aimed at reducing discrimination of PLWHA or people affected by HIV/AIDS. Progress and achievements Based on the reports, interviews and group discussions, it is notable that the Namibian government and other stakeholders at both the national/central and regional level have a fair understanding of the progress, and the gaps and challenges in the implementation of MTP III. All stakeholders know about the MTP III, have a copy of it, and almost all are aware of what is expected of their sectors and ministries. The difficulty, however, seems to be in designing and implementing effective strategies that address these problems, and finding efficient systems to address these challenges. Key issues The multisectoral response, particularly in the public sector where HIV/AIDS is not yet systematically mainstreamed, is relatively underdeveloped. Current systems for the coordination of the national HIV/AIDS response have not yet been able to facilitate broad ownership and participation of all ministries involved, despite high awareness of MTP III targets. It is not always sufficiently understood that the national AIDS response consists of two distinct responses: 1) the Health sector response, and 2) the expanded national response or multisectoral response. The dynamics, coordination mechanisms, support needs and responses of these two categories are distinct. Other sectors have other core mandates though, and need assistance in identifying strategic ways of responding to HIV/AIDS within their mandate. The sub-directorate responsible for an expanded HIV/AIDS response is currently not sufficiently equipped to coordinate and provide technical support to other sectors in enhancing implementation of the multisectoral response, in addition to its monitoring leadership. The enabling environment component of the MTP III focuses mostly on the needs and rights of the infected and affected population, and lacks a long term vision on how to address prevention for people not yet infected. 12

13 Sub-component 1.1: Sustained Leadership Commitment Expected outcome: 80 percent of political, religious and traditional leaders and other opinion setters advocate for behaviour change, reduced discrimination and stigma, and access to services and care. Progress and achievements In an effort to facilitate sustained leadership commitments, investments were made in capacity development of leadership to advocate for behaviour change, reduce discrimination and improve access to services. HIV/AIDS workshops were organised after the 2004 elections as part of the induction training,for parliamentarians, local authorities, religious and traditional leaders, and focal persons in ministries. The workshops were coordinated through the MoHSS-DSP with support from other stakeholders. The focus varied from general information, to developing better understanding of HIV/AIDS, its impact, and relationship with human rights and poverty. Key issues and challenges: The section on sustained leadership commitment is biased towards the mitigation of stigma and discrimination, neglecting other leadership functions in the response to AIDS. Emphasis is also put on workshops and allocating financial resources for HIV/AIDS activities. Accordingly, a variety of government stakeholders mistakenly see inclusion of HIV/AIDS talks in political leaders speeches as an indicator of commitment. There is poor articulation and monitoring within the MTP III of the strengthening of the overall leadership for the expanded national HIV/AIDS response. This includes the specific role of ministerial leaders in articulating, implementing and being accountable for relevant HIV/AIDS responses in their ministries. Most line ministries have not yet implemented the majority of commitments made in the MTP III, despite political commitment reportedly being in place, although in some areas significant progress has been made. A gap in leadership remains evident as activities to sensitise leadership have not yet led to increased ownership and engagement of senior managers and human resource managers for mainstreaming of HIV/AIDS in their ministries. There is a suboptimal representation of top level leaders in the national coordination bodies, such as NAC and NAMACOC, apparently due to the MoHSS convening the meetings, rather than an office with authority to invite other ministries. Currently the HIV response is overly delegated to a lower level that lacks guidance and supervision in ministries. This is a consequence of prioritising parliamentarians above guidance for fostering measurable commitment and leadership among senior officials. Few leaders have as yet spoken about how they are personally affected by HIV/AIDS, which in other countries has been a major factor in addressing stigma and discrimination. There is a strong faith based response, but limited to Christian faith. Muslim leaders consulted were unaware of MTP III, but do provide support to HIV positive members of the congregation. HIV could be mainstreamed into training programmes in the mosques that target youth, men and women. Recommendations: Assign the overall responsibility of the HIV and AIDS response to the Office of the President and establish a well resourced secretariat to ensure human resource capacity to manage the overall response. 13

14 Create an environment in which targeted interventions for particularly vulnerable sub-populations for HIV are supported through e.g. arranging small scale exchange meetings between key decision makers and representatives from these sub-populations, through field visits within and outside of Namibia, through legal reviews, etc. Engage the parliamentary standing committee on Human Resources, Social welfare and Community development in the monitoring of the ministerial responses. Continue to promote the active involvement of traditional leaders in the response. This will assist in addressing some of the traditional practices that fuel the epidemic, such as widow inheritance; contribute to reducing stigma and discrimination; and ensure community involvement in taking responsibility for mitigating the impact of HIV/AIDS. Ensure continued involvement of faith based organisations, and encourage inclusion of non-christian faiths. 14

15 Sub-component 1.2: Greater Involvement of PLWHA Expected outcome: 100 percent participation of PLWHA in planning, decisionmaking and implementation for the expanded human rights response to HIV/AIDS. The goal of this sub-component is to facilitate greater involvement of PLWHA in decision-making, planning and implementing the human rights response to HIV/AIDS. The prioritised activities include capacity building of PLWHA and active involvement of PLWHA in planning and implementation of activities, and involvement in decision-making bodies. Progress and achievements Technical assistance was provided to Lironga Eparu, the main PLWHA support organisation, to support its organisational development. A vision and mission, strategic goals, and implementation plan were developed, and the organisation restructured, with additional staff and funds. Lironga Eparu appointed focal persons in a number of constituencies who are expected to support local PLWHA peersupport groups, providing peer counselling, treatment support, psychological support, skills training to PLWHA, OVC bereavement counselling and succession planning. PLWHA support groups advocate for equal access to services and offer support in cases where people are refused certain services. Over the past year, Lironga Eparu reached almost 6000 PLWHA out of the estimated 230,000 people living with the virus in Namibia.. Progress has been made in the Greater Involvement of People Living with HIV/AIDS (GIPA). Involvement means that PLWHA are invited as speakers, serve as role models, service recipients, experts, and occasionally in senior management levels in HIV/AIDS organizations, though the impact of this involvement on the national response remains limited. The benefits of GIPA are perceived by stakeholders as: reduction of stigma and shame associated with HIV; enhanced self esteem and self worth; access to comprehensive care and support; inclusive and relevant HIV/AIDS policies and programmes; more focused and ethical research; more effective HIV/AIDS communication strategies; and increased visibility of PLWHA and legitimacy of their organisations. GIPA ensures an ethical and comprehensive response to the epidemic. Achievements to date include representation of PLWHA in various implementation and coordination structures including NAMACOC, RACOCs and NAEC. Representation in other interventions, such as monitoring meetings and processes, has been reported. The involvement is mainly through Lironga Eparu, and NANASO, a network for the AIDS service organisations. A reasonable number of PLWHA have openly declared their HIV status, which could indicate a reduction of stigma and will itself further reduce stigma. 15

16 Key issues and challenges: There remains limited awareness, among stakeholder including PLWHA, of GIPA as a principle in responding to HIV/AIDS. Barriers to GIPA include: stigma and discrimination leading to isolation and shame; lack of basic knowledge, skills and resources to foster meaningful involvement; negative attitudes and unwillingness to engage PLWHA by some organisations and structures implementing HIV/AIDS programmes; GIPA is still undefined and lacks policy and legal backing and support; poor understanding and interpretation of GIPA principles by key stakeholders including some PLWHA networks; and problems in promoting GIPA as an effective instrument in the broader HIV/AIDS response. PLWHA Network/support groups and associations employ varied definitions of GIPA, but all agree that GIPA should lead toward a meaningful and full involvement of PLWHA in the national response at all levels. The public and private sector implementing HIV/AIDS programmes have very little understanding of the principle of GIPA and even where they engage with PLWHA, they do not do so with the GIPA concept in mind. Respondents from the NGOs working in HIV/AIDS have a better understanding of GIPA and indicated that PLWHA voices should be heard and integrated in all policy and decision-making fora. Lironga Eparu appears unable to fully embrace its critical role in representing the PLWHA community, despite making considerable progress in improving its organizational structure. There are PLWHA support groups who decline to be part of Lironga Eparu, and still others who are oblivious to its existence, for example Etunda in the North. Some local authorities invest extensively in processes to include PLWHA representation. In RACOC they have even planned conferences to stimulate HIV representation, yet fail to articulate their expectations from PLWHA participation. PLWHA and the majority of community members know little of the frameworks and policies since these were developed with little consultation of concerned stakeholders. The technical language in these policy documents renders them incomprehensible to many PLWHA, who are thereby denied knowledge of their rights within the context of the policy, and whom they can hold accountable. Recommendations: Review how all PLWHA support groups can be represented in Namibia and how GIPA principles can be fully operationalised throughout all components of the national AIDS strategic plan, with PLWHA facilitated to be actively involved. Develop and support the transition for Lironga Eparu to have the relevant governance structure, technical and resources capacity to embrace its role of giving visibility to PLWHA and facilitating active involvement of support groups at all levels to be involved effectively in prevention, treatment and care, and mitigation of socio-economic impact. Develop a clear GIPA definition and guidelines for implementing GIPA at all levels. This should include guidance on mainstreaming GIPA in HIV/AIDS programme implementation, and at line ministries in processes around developing policies, guidelines, planning of programmes and monitoring and evaluation. Engage PLWHA networks in the MTP III programme expenditure for increased budgetary allocation. Develop a GIPA result framework including indicators to measure implementation, and compare GIPA successes and case studies in Namibia and other countries. Improve awareness and knowledge on human rights targeting PLWHA, and enhance training on treatment literacy and adherence. Elaborate on purposes and functional mechanisms to foster participation of PLWHA in future plans, to avoid tokenism and involvement of PLWHA simply as a legitimising process. 16

17 Sub-component 1.3: Policy and Law reform Expected outcome: National HIV/AIDS policy is developed by 2004 and relevant law reform is undertaken to create a framework to reduce vulnerability, to improve access to prevention, care, support and treatment services and to mitigate the impact by All sectoral and institutional HIV/AIDS related policies are developed or reviewed in conjunction with the national policy to ensure an expanded multisectoral and human rights approach by The theme of policy development and law reform prioritises a national policy on HIV/AIDS, the review of existing legislation and policies, and enactment of new ones. The Ministry of Justice is the lead agency for most activities in this sub-component, which also calls for sectors and institutions to reform sectoral policies in line with the national HIV/AIDS Policy. Progress and achievements The national policy on HIV/AIDS was recently completed, and approved by the national assembly on 14 th March 2007, and will soon be launched and distributed. The policy aims to provide a supportive policy environment for implementation of HIV/AIDS programmes that reduce new infections, improve treatment care and support and mitigate the impact of HIV/AIDS. The policy also offers a basic frame for responding to HIV/AIDS in the workplace, M&E, surveillance and research, and institutional framework for policy implementation. Encapsulated in the policy is the creation of an environment facilitating the protection, participation and empowerment of vulnerable and marginalised groups including PLWHA; driving prevention of HIV through behaviour change communication, VCT, condom promotion, PMTCT, STI treatment, blood tissue safety, enforcement of universal precaution practices in health services and other settings, and facilitated access to PEP. NAC is said to be responsible for advising cabinet on HIV/AIDS, NDP 3 is expected to enable overall policy implementation. Key issues and challenges: In the absence of a comprehensive study and analysis of various acts and policies it is not possible to prioritise the laws and acts that need to be reformed and the new areas that need to be regulated. Only recently did the Ministry of Justice decide to prioritise research in the area of HIV/AIDS and the law, though this process has yet to begin. Due to the long delay in completion and approval of the national HIV/AIDS policy, ministries and institutions have as yet been unable to reform or develop sectoral policies.. Recommendations: Analyse current legislation to provide information to enable the setting of reform targets. Prioritise implementation and monitoring of implementation of current laws and policies, and provide legal aid to facilitate access to courts (litigation and retribution) by violated individuals who could otherwise not afford this service. Legal reform in support of targeted interventions for specific vulnerable subpopulations such as MSM, prisoners and female sex workers, would ensure that such interventions would be undertaken in a more efficient and larger scale 17

18 Sub-component 1.4: Interventions to reduce stigma and discrimination Expected outcome: Appropriate and accessible social mobilisation aimed at reducing discrimination against, and stigmatisation of, those living with and affected by HIV/AIDS, other STIs or TB. Counselling and legal assistance is provided to all persons living with or affected by HIV/AIDS/STI or TB who have suffered discrimination and stigmatisation and request such assistance. The MTP III emphasises the need to invest in measures to address stigma and discrimination. Core activities include social mobilisation and interventions/ actions to reduce stigma and discrimination (law enactment, capacity building and legal services and policies implementation), including translation of human rights for PLWHA into acceptance by all communities. Progress and achievements Government and NGOs have implemented a number of awareness activities at central and regional levels, with stigma to be addressed in RACOC discussions, and plans and reports. Efforts to involve and cater for the needs of PLWHA is evident in the national HIV/AIDS policy, code on HIV/AIDS and employment, NABCOA programmes, and medical schemes providing HIV/AIDS health cover. Agencies, such as the Aids Law Unit Legal Assistance Centre, help clients in contesting discrimination cases, and thereby contribute to the interpretation of law to address discrimination. Key issues and challenges: A neglected area in the MTP III is the setting up of mechanisms that facilitate development of a positive attitude among service providers toward PLWHA, including the training of social workers and justice officials, and establishment of a body to investigate cases of discrimination. From interviews, it is notable that fear of stigma and discrimination is high among PLWHA and other marginalised groups, and this fear affects their ability to access available services. In the case of MSM, the fear is compounded by existing stigma they experience as a community. Issues around stigma continue to hamper efforts to scale up prevention and treatment, despite some anecdotal evidence indicating people are less fearful of visiting and being seen at CDC clinics in the country. Still little is known about how stigma affects PLWHA and their families, how it influences prevention and care efforts, and which measures might best reduce stigma and discrimination among different population groups. The official bodies in place to oversee law enforcement and investigate cases of discrimination, such as the office of the Ombudsman and LAC-ALU, have limited capacity to take up these roles. Recommendations: Enhance the quality of services, especially in the areas on non-discrimination and confidentiality. Services are advised to be receptive to a range of groups (including those performing acts classified as illegal) as they are actors in the spread and control of infections. Improve understanding of how stigma affects PLWHA and their families, how it influences prevention and care efforts, and which measures might best reduce stigma and discrimination among different population groups. 18

19 COMPONENT 2: PREVENTION Expected outcome: To reduce incidence of HIV infection below the epidemic threshold of one percent. Progress and achievements The 2006 HIV prevalence data indicate that HIV prevention efforts have so far failed to turn the epidemic around. This does not mean there are no positive developments in the prevention field. One of the most noticeable changes is the launch of the Smile condom through which free condoms have become available in large quantities and which has resulted in normalization of condoms. Another important achievement is the sharp increase in people visiting Voluntary Counselling and Testing (VCT) centres due to diversification of VCT options and the availability of anti-retroviral drugs (ARVs). A number of NGOs have stepped into the void of social mobilization and started massive social mobilization campaigns. An example of this is Development Aid from People to People (DAPP) who, through their Total Control against the Epidemic (TCE) campaign, targets nearly half of the Namibian population with door-to-door interpersonal communication. Lastly, there is some indication that the massive targeting of youth, both in and out of school, may well have resulted in youth reporting higher levels of condom use and more VCT visits. However, at the same time, larger numbers of youth report to have higher numbers of sexual partners. Key issues and challenges Namibia is facing tremendous challenges to turn the tide. A first challenge is that of the absence of an evidence-based prevention strategy which could provide strategic direction for better coordinated prevention responses. Secondly, there is little deeper understanding of how the epidemic spreads in Namibia and what the driving forces are behind localized epidemics. Furthermore, there is not one single government body assigned to coordinate all prevention efforts. Another key challenge is that of behavioural change capacity. Communication and facilitation skills of those involved in interpersonal communication, including life skills teachers and social mobilization fieldworkers, need to be enhanced and Behaviour Change Communications (BCC) support materials developed that address issues such as risk-perception, sexuality, alcohol and substance abuse, violence, etc. Interpersonal communication efforts also need expansion to rural areas and intensification so that the same person is reached more than two or three times. At the same time interpersonal communication efforts also need to be closer linked to other components such as VCT, sexually transmitted infections (STIs), Prevention of Mother to Child Transmission (PMTCT), post-exposure prophylaxis against HIV infection (PEP), Tuberculosis (TB) and TB-HIV. Male circumcision could become a new evidence-based intervention in the prevention mix, once feasibility studies indicate this could be successfully done. Increasing male involvement is another challenge as men are found to be the main decision makers when it comes to (safer) sex in Namibia. Some organisations have successfully piloted male only and community level activities for men organised by traditional leaders for which high numbers of men turned up. While there are promising initiatives that target some very vulnerable groups such as men who have sex with men (MSM), female sex workers, prisoners, mobile populations such as soldiers and police, and PLWHA, these initiatives need to be expanded both geographically and in terms of services provided. Finally, income-generation and micro-financing initiatives are simply too few and of too small a scale to seriously address poverty, one of the driving forces behind HIV. 19

20 Sub-component 2.1: Strengthen Capacity to Deliver HIV/AIDS Prevention Programs Expected outcome: 100 percent of organizations and individuals delivering prevention interventions have improved knowledge and skills on HIV/AIDS and behaviour change Progress and achievements A host of trainings have taken place over the last few years to strengthen the capacity of organizations and individuals to deliver prevention programmes. As mentioned in the MTP III progress report these trainings included: Training of Regional AIDS Coordinating Committees (RACOCs), capacity building of umbrella bodies such as Namibia Network of AIDS Service Organisations (NANASO), Lironga Eparu and Namibia Business Coalition of HIV/AIDS (NABCOA), training on VCT, PMTCT, life skills and social mobilization through outreach and peer education. All in all, hundreds of people have been trained in different subjects. Furthermore, the decentralization process has helped to strengthen several regional offices of line-ministries. Over the last 18 months for instance, the Ministry of Education has recruited Regional HIV Education Officers who are now added to the regional education teams. Having full time officers to coordinate and monitor HIV education activities is a good step forward towards delivering HIV prevention in the regions. Another example is that of the Ministry of Gender Equality and Child Welfare, who have also increased their regional level staff capacity. Key issues and challenges In spite of the many trainings mentioned above, there are a number of challenges in the HIV prevention field that limit the capacity of organisations and individuals to make effective contributions to HIV prevention. Although the MTP III is a comprehensive one, compared to many other strategic plans in the world, it does not contain an evidence-based HIV prevention strategy. Formulating such a strategy would seem to be a first essential step towards responding more effectively to the epidemic and therefore moving towards the overall objective of MTP III of reducing HIV incidence below the one percent threshold. A related issue is that no single government body has been assigned the overall responsibility for prevention, ensuring a holistic strategic approach, overseeing its implementation and monitoring its effectiveness. The Ministry of Information and Broadcasting is responsible for coordinating BCC and social mobilization; the Ministry of Health and Social Services for services such as STI, VCT, We need a strategy to guide how to go about prevention. People misunderstand prevention. They think it is about BCC only, but they forget about the linkages with VCT, STI, condom promotion, HBC, OVC etc. PMTCT, PEP, and condom promotion; the Ministry of Education for in and out of school programmes; the office of the Prime Minister for HIV in the workplace, etc. The national response is missing a monitoring system that can a) provide deeper insight into the most important drivers of the epidemic; b) monitor whether the strategy is effective and; c) monitor whether epidemic dynamics are changing and necessary adjustments in the response are in place. Another big challenge is building capacity for behavioural change. While many people have been trained, many of those trainings focused on providing basic information on HIV or on how to mainstream HIV. Less focus has been given on building capacity for behavioural change communication and how to manage and 20

21 monitor behavioural change programmes effectively. Being able to select who would make good communicators for behavioural change is also a much needed skill. This is especially crucial as the Ministry of Information, who according to MTP III is responsible for BCC, informed the review team not to have the resources for this, and that it is up to civil society to undertake these activities. Although there are some very good Information, Education and Communication (IEC) materials at national level mostly focusing on young people, behavioural change tools and community level BCC capacity seem to be lacking. There is a lack of availability of tools and facilitation techniques to address misconceptions and myths, to link people s aspirations/desires with HIV and to facilitate real dialogues around sex and sexuality including looking at traditional cultural practices and values. There are also several staffing issues that need to be addressed in relation to prevention: People involved in prevention efforts are not isolated from the rest of society and equally affected by the epidemic. Reports coming from the field indicate that substantial numbers of outreach workers, peer educators, teachers, etc. are infected with HIV. A report on the impact of HIV on education in Namibia (2002) by the Ministry of Education also states that this results in higher levels of absenteeism because of illness or funeral attendance, poorer levels of teaching by chronically ill teachers, loss of skilled teachers and complications in staff replacement, allocation and distribution. Stepping up HIV in the workplace initiatives for those involved in prevention would a) help reduce new infections and b) build an enabling environment that facilitates access to ARVs and treatment and care and as a consequence reduce morbidity and mortality among staff. However, it seems that many of the workplace programmes have either not yet been initiated or are only in the start up phase. The Human Resource Guidelines for all civil service employees do not all comply with equal treatment and best practices. Staff recruitment procedures are said to be lengthy and cause severe staffing gaps for longer periods of time. Many activities depend on large numbers of volunteers such as My Futures is My Choice. The low financial compensation causes quick volunteer turn over. Some line-ministries have only very small regional offices and are therefore not able to follow up on tasks assigned to them in MTP III. The Ministry of Information and Broadcasting is for instance not able to coordinate regional community mobilization efforts. Some ministries, such as the Ministry of Education, have difficulty coordinating and monitoring the regional response from the national level. Stronger management and monitoring skills within Ministry HIV units are needed for ensuring leadership to the regions. In the past few years, the STI control programme and the Namibia Blood Transfusion Services (NAMBTS) have been hampered by the lack of human resources and technical capacity. Regional and constituency level monitoring capacity for ensuring that activities take place, that they are of good quality and that problems get identified in a timely fashion constitute a big challenge. Many institutions lack transport for monitoring and/or do not have sufficient staff to undertake regular monitoring. Lastly, people living with HIV/AIDS are not sufficiently part of the HIV prevention response. While everyone agrees that involving people with HIV is important, this has not happened on a large enough scale, due to capacity problems. 21

22 Recommendations Assign the overall responsibility for prevention to the Office of the President and establish a secretariat to support the OP with prevention coordination. Conduct research on epidemic dynamics both at the national level and within regions to inform the evidence-based strategy. Based on the study results, priority sub-populations should be identified for whom prevention efforts should be stepped up with the highest urgency, while general less intensive prevention efforts would continue for the rest of the population. The prevention strategy should also include linkages with other initiatives in the country such as poverty reduction efforts. Strengthen monitoring systems so that behavioural change can be reviewed on annual or bi-annual basis and programmes adjusted according to the findings. This will also allow the indicators of the MTP III to shift from output indicators to outcome/impact indicators. Build capacity for behavioural change through capitalizing on small scale successful activities such as AIDS and me developed by IBIS in Namibia and through adapting BCC tools developed in other countries which will facilitate skills building and motivation for behavioural change. Also use could be made of the already trained 224 community level communicators and 1800 trained peer educators (trained by various NGOs). Their BCC skills could be strengthened and they then in turn could assist with building BCC skills of others. Document and share trial and error approaches to create an enabling environment for people to pilot new approaches and to reduce training dependency. Staffing: o Step up HIV in the workplace activities to a) reduce new infections among those involved in prevention efforts such as teachers, health care providers, policy makers, volunteers, NGO and CBO staff, etc.; and b) ensure an enabling environment so that people in need can access ARVS and treatment and care. o Revisit the Human Resource guidelines for all civil service employees and ensure compliance to equal treatment and best practices is up dated and current. When interviewing and recruiting new staff members ensure the issues of stigma and discrimination are thoroughly covered on how an employee should conduct his/her self at all times. Include statements, in employment contracts, on punitive actions if stigma/discrimination complaints are made against the employee. o Strengthen human resources and technical capacity for STI management and blood safety at all levels of the health care delivery system. o Explore whether recruitment for HIV related positions can be fast-tracked. o o Review how volunteer turn over can be addressed. Strengthen the planning, coordination and monitoring capacity of National, RACOC and CACOC staff. Strengthen linkages between BCC activities and VCT, PMTCT, STI and PEP and strengthen the involvement of people living with HIV in prevention efforts. 22

23 Sub-component 2.2.1: Target behaviour change interventions for vulnerable populations Expected outcome: Targeted behaviour change communication interventions (IEC, male/female condom provision, STI, VCT, PMTCT and post exposure prophylaxis for rape survivors). Progress and achievements Since the start of the Military Action and Prevention Programme (MAPP) of the Ministry of Defence in 2001, close to 10,000 soldiers have participated in five to eight hour edutainment sessions. In 2006/2007, the project opened two military VCT sites in which so far over 700 soldiers have been tested. Soldiers involved in peace keeping missions have been provided with leaflets and condoms. The PolAction prevention programme has been set up by the Ministry of Safety and Security in 2005 for police. The MTP III progress report mentions that the project has been successful in mobilising high-level support and in reaching approximately 25 percent of the police force with prevention, care and support activities. Prisoners have been sensitized about their rights to access information specifically relevant for themselves and their families. Supportive environments are created amongst HIV positive inmates with involvement of HIV negative peers. Occupational programs and skills building opportunities such as wood carving, mechanics and vegetable gardening for inmates have been set up. Inmates have access to relevant social and medical care, and they gained strong awareness of HIV and how to prevent the virus from spreading. A missing component however is condom distribution in prisons. The Namibia Institute for Democracy conducted research on sex work in Windhoek. The researchers estimate that there are approximately 1,240 sex workers in Windhoek alone. Various support systems are up and running for female sex workers by NGOs and FBOs. A small though significant initiative for care and support for sex workers is unfolding in Katutura, Windhoek, with Father Herman sensitizing over 3,000 young and out of school girls. The Namibian Counsil of Churches (NCC) provides skills building training for girls that want to step out of sex work and earn money in a different way. NaSoMa conducted an education campaign for truck drivers and sex workers in Caprivia, Kavango and Oshikango and Social Marketing Association (SMA) has also been involved in similar activities in border areas such as Oshikango and Caprivi. Several support mechanism for PLWHA are in place, although these cannot always be accessed (lack of transport and other reasons). The Rainbow Project (TRP) and Sister Namibia are two NGOs that have strong experience with gender and sexuality training. Sister Namibia has conducted training of trainings on HIV prevention, sexual rights and women empowerment in over 50 locations in Namibia. TRP has conducted training on sexuality and gender identities in 11 centres, has also been involved in STI campaigns in relation to positive living, and has been distributing safer sex materials produced by TRP and by South African and Zimbabwean partner organizations. The NGO Sister Namibia is also the creative force behind the 50/50 campaign, ensuring more women getting actively involved in politics in Namibia, involving schools, churches, traditional leaders, regional and local councillors, all in all 23

24 reaching out to more than 100,000 people. The same organization also publishes an internationally renowned magazine that is widely distributed from policy makers to grass root level and which promotes empowerment, women claiming their sexual rights, challenges cultural beliefs and practices and promotes equal human rights of all sexual minorities with a focus on lesbian women. The blind have been assisted with information materials in Braille and audiotapes which received international recognition. The mentally and physically handicapped were sensitized through special care programs and workshops. Key issues and challenges 1 While everyone is at risk because of the very high prevalence levels in Namibia, this does not mean that everyone is at equal risk. However, the lack of deeper understanding of how the epidemic spreads in Namibia and the driving factors behind localised epidemics make it hard to establish who is most vulnerable to HIV. This also makes it hard to determine through which strategy HIV incidence could most effectively be reduced. It can safely be assumed that female and male sex workers are particularly vulnerable to HIV because of their wide sexual networks and their limited skills to negotiate for safer sex because of poverty and having to operate in locations where condom negotiation is difficult. Although no data could be found on the number of clients sex workers have per day or week, a UNFPA study in showed that six percent of sexual active male between year of age had had sex with a sex worker in the past 12 months. The number of interventions targeting sex workers in Namibia and their actual coverage is very limited. Making sex work safer through a range of activities such as i) peer education addressing negotiation skills, safer sex options, dealing with alcohol, self-esteem, violence etc.; ii) increased access to improved STI management; iii) access to male and female condoms and lubricant; iv) access to care and treatment; v) saving schemes and; vi) alternative income generation options could strongly reduce new infections stemming from commercial sex. Besides commercial sex, studies also indicate high levels of transactional sex. The sugar daddy phenomenon where older men from age cohorts with very high prevalence levels have sex with teenage girls, is wide spread. A NawaLife study 3 found that around one in ten young males and nearly one in three young females who had ever had sex reported that their last sexual partner was more than ten years older than themselves. This pattern was similar among the year and the year age cohorts. This leads to large numbers of young girls and boys to become infected with HIV. In turn, as these young people also have sex with their peers, they may pass on the virus among the younger age group. A UNICEF Knowledge, Attitude, Practices and Beliefs (KAPB) study 4 reports that among the years age group, close to six percent of the males had had anal 1 For the key issues around the HIV vulnerability of women because of gender inequality, please see prevention section 2.5 Addressing vulnerability based on gender inequality, violence and alcohol abuse. 2 Baseline on Sexual and Reproductive Health and HIV/AIDS among Adolescents and Youth, 2002, UNFPA 3 HIV/AIDS Strategic Information Report : Lifestyles, Knowledge, Attitudes and Practices A Mid Term Household Analysis of Residents from Keetmanshoop, Oshakati, Rundu and Walvisbay. May Nawa Life 4 HIV and AIDS Knowledge, Attitudes, Practices and Behaviour (KAPB) Study in Namibia: Key Findings, November 2006, UNICEF 24

25 sex with one or more partners, while close to two percent of females reported to have had anal sex. In a 2002 UNFPA study 5 nearly four percent of sexually active male youth were said to have had male sexual partners. A focus group discussion with MSM in Windhoek reinforced the idea that male-to-male sex is quite common and showed that people are not well aware of the high HIV risk of anal sex. It is obvious that BCC activities for MSM, but also in relation to anal sex in general, need to be expanded. Linkages between BCC and STI, VCT and care and treatment options for MSM, who are now afraid to access these service because of fear of stigma, need to be strengthened. Currently The Rainbow Project (TRP) is the only organization in Namibia working with MSM. TRP has their head office in Windhoek but recently also opened a satellite office in Ongwediva. Efforts to reach migrant sub-population groups need to be stepped up. Research that would look further into the vulnerabilities of migrant groups both in the source and destination communities (including cross border), would be helpful to define further strategies of which migrant groups should be reached as a priority and how best to reach these sub-populations. Cross border movement in areas such as Katima and Tsumeb, need to be studied. People living with HIV and AIDS are also particularly vulnerable. Unemployment and the lack of food enhances the vulnerability of many PLWHA. Prevention and care efforts among this group need to be stepped up to reduce the risk of reinfection and the risk of passing the infection on to others through unsafe sex. The current level of effort to decrease poverty is by no means enough to seriously have an impact. Research in Namibia indicates that the high levels of unemployment and lack of perspective drive people to alcohol abuse which in turn is linked to higher levels of unsafe sexual practices. Poverty drives people to sell sex either for money or for goods. Lastly, people who are not well nourished are more likely to have weaker immune systems and thereby a higher risk of becoming infected when exposed to the virus. Recommendations: 6 Research epidemic dynamics, both at the national level and within regions, to inform an evidence-based strategy. Such research would provide better insight in levels of vulnerability and the different elements that contribute to this vulnerability. Identify priority sub-populations, based on the study results, for whom prevention efforts should be stepped up with the highest urgency. Include linkages with other initiatives in the country such as poverty reduction efforts, in the prevention strategy. Advocate to build support and a supportive legal framework for targeted prevention interventions for female and male sex workers. Rapidly expand current activities for female and male sex workers. Interventions for these groups should also make efforts to motivate clients of sex workers to increase their condom use. Training for STI service providers on management of STI in nonmainstream women would also be required. Develop strategies to more effectively address the Sugar Daddy Phenomenon and include in activities for in and out of school youth and in activities targeting men in the Sugar Daddy age group. 5 Baseline on Sexual and Reproductive Health and HIV/AIDS among Adolescents and Youth, 2002, UNFPA 6 Please note that recommendations to reduce the HIV vulnerability of women have been included in sub-component 2.5: Addressing vulnerability based on gender inequality, violence and alcohol abuse. 25

26 Increase activities in relation to Male Sexual Health. A pioneering needs assessment from July-September 2007 is being organized to identify requirements to make MSM aware of HIV prevention, as well as care and treatment availability. Put in place links between MSM and VCT and STI facilities so that MSM can more easily access these services. Conduct training for key VCT workers to make them familiar with men who have sex with men, to remove misconceptions and make them aware of discriminatory behavior and body language,. The Rainbow Project and Sister Namibia could contribute to taking this forward. Provide training for STI service providers on management of anal STIs for both men and women. MSM in Namibia are not an isolated group. Most MSM have both male and female partners. Reducing HIV in MSM would therefore also contribute to a reduction of HIV through male to female sexual networks. Make available water-based lubricant to replace the currently used cooking oil, petroleum oil (Vaseline) and body lotion which are known to damage latex. Make Condoms available for prison populations, where male-to-male sex, as is the case everywhere in the world, is known to be common. This should go handin-hand with advocacy efforts that would build an enabling environment and supportive legal framework for this activity. Create an enabling environment in which targeted interventions are supported. Organise advocacy meetings with involvement of NGOs and representatives of the target groups. During these meetings, address issues of legal protection. Increase interventions that address mobile/migrant population groups. Priority populations within this group that should be reached with the highest urgency should be defined by the above mentioned research on epidemic dynamics. In relation to cross border activities, the Primary Health Care unit of the MoHSS has been working with their counterpart neighbours on health care issues and immunisation among others in some regions. It would be good if the appropriate MoHSS officials from Windhoek and the Regional AIDS Coordinators (RACs) could join in on these discussions. Expand prevention efforts among people living with HIV and AIDS to address reinfection and new infections and improve access to treatment and care. Expand and diversify efforts to reduce poverty among others through income generation and micro-credit. 26

27 Sub-component 2.2.2: Prevention of HIV Transmission in Health Care Settings Expected outcome: All health facilities adhere to national infection control and post exposure prophylaxis (PEP) policies. Progress and achievements The Government of the Republic of Namibia has put in place statutory instruments to safeguard the welfare of the workforce including health care workers. MoHSS in collaboration with the Ministry of Labour and Ministry of Mines and Energy is spearheading the implementation, monitoring and control of the relevant legislation relating to health issues in the various workplace settings. In the MoHSS, the Post Exposure Prophylaxis programme (PEP) is under the Division of Occupational Health and Safety (Directorate of Primary Health Care (PHC)). The Infection control programme is managed separately under another division. Funding for the programme is primarily from government through the directorate of PHC. MoHSS finalized its National Guidelines on Post Exposure prophylaxis at the workplace in July Two thousand copies were printed and distributed to all regions. The Occupational division has developed the National Occupational Health Policy (July 2006). It recently submitted its plan to the overall National Development Plan III ( ). It was reported that about nurses were trained on occupational injuries and PEP in 2004, while 17 doctors underwent the same training in No training was conducted in 2006 due to financial constraints. Medicines for PEP are now available for occupational exposure at all district hospitals. A total of 112 health workers have received PEP countrywide since the introduction of the programme. Of note is that the private sector is doing better in terms of providing occupational health services. MoHSS finalized a memorandum of understanding with the University Research Council (URC) to support implementation of injection safety efforts and has developed regional waste management guidelines. It is envisaged that the waste management programme will be scaled up and critical training of health workers in safe injection and waste management practices continued. Initiation of private health care providers in injection safety dissemination meetings have been started. Namibia Institute of Pathology (NIP) has appointed a Health and Safety Officer who is tasked to set up a section dealing with safety issues throughout the network of NIP s laboratories. Local manufacture of sharp containers is underway and MoHSS will take over responsibility of supplying disposal containers. Key issues and challenges: The management structures for the Occupational and Safety programme are unclear. Furthermore, there is inadequate human resource capacity at all levels i.e. the programme has had no National Chief Medical Officer for the last two years and no Occupational Hygiene Officer for the past five years. There are also no structures at regional and district level to spearhead the programme. The financial resources for the programme management, procurement of equipment, etc. are insufficient. Statistics on occupational injuries in particular needle stick injuries and outcome data in the country are inadequate. This is partly due to under reporting of cases and unavailability of a standard reporting system 27

28 Health care workers suffering needle stick injuries may not always report the incident because of the requirement to undergo baseline HIV testing. The completion of occupational incident exposure and compensation forms is inadequate for both the public and private sectors. There are no staff clinics within health facilities to provide services specifically for the health care workforce. Some health facilities still experience stock-outs of safe sharp waste containers due to transport problems. Health care workers are not well versed on the TB infection control policy. Recommendations: Strengthen and clarify the management structures for Occupational Health and safety at all levels of the health delivery system. Mobilize more resources for all components of the programme as the MoHSS cannot function efficiently and effectively without a healthy workforce. Sensitize all health workers on Occupational Health (including PEP) and safety so that the health workforce makes use of these services and knows their legal rights pertaining to exposure to HIV in the workplace. Include attention in the training on the Rape Policy and strengthen the link between police, social workers and medical facilities to ensure smooth referral. Develop a standardised reporting system and train all parties involved on the importance of proper data management and programme monitoring. Make adequate sharp containers available through addressing bottlenecks related to transportation, storage, use and proper assembly of the containers. Ensure that TB infection control among health workers is urgently addressed, especially for multi-drug resistant TB (MDR-TB) and possibly extensively-drug resistaint TB (XDR-TB). HIV positive health workers should best not work in TB wards. 28

29 Sub-component 2.3: Behaviour Change Interventions for young people Expected outcomes: 100 percent of children receive behaviour change communication in primary schools and behaviour change interventions in secondary schools 100 percent of youth in tertiary education and out-of-school youth have access to behaviour change interventions (BCIs) Progress and achievements Primary and Secondary School Youth Approximately three out of four primary schools are implementing the Window of Hope (WOH) Junior (grade 4 and 5) and one in five primary schools the WOH Senior (grade 6 and 7) 7 after school life skills programmes. The My Future is My Choice (MFMC) life skills programme for secondary schools reaches around 14,000 learners per year 8. Both WOH and MFMC address sensitive issues such as sex, sexuality, condom use, puberty, alcohol abuse, stigma and discrimination and teenage pregnancy in age appropriate formats. The Ministry of Education is also in the process of integrating life skills in the school curriculum for grades A training manual for this purpose has just been finalized. Evaluation reports indicate that youth who participated in WOH/MFMC have increased self-confidence, improved communication and social skills, better relationships with peers including the opposite sex, better overall school performance rates, and are more comfortable to discuss sexual matters with elders (mainly parents) Students and Out-of-School Youth Efforts to integrate HIV in tertiary education institutions remain limited. The MTP-III progress report (March 2007) mentions that nearly half of the Namibian youth is being reached through a combination of clubs, sport events, interactive drama, puppet shows, peer education and door-to-door outreach. Youth are also targeted through magazines (Desert Soul, Open Talk and Oyo) and radio programmes, as well as through mass media campaigns such as Take Control. In several of these initiatives youth are involved in the planning and implementation of the activities. A number of organisations emphasise the importance of letting youth reflect on the choices they have instead of telling them what they should (not) do. Overall achievement in relation to youth While the HIV prevalence rates among pregnant women for the and the age groups have slightly increased over the last two years, the HIV prevalence rate of the age group has reduced from 22 percent in 2002, to 18 percent in 2004 and 16.4 percent in The DHS 2006 preliminary data show a decline in teenage pregnancy and motherhood in urban areas (from 17percent to 12 percent) but this did not apply to the rural areas where the level has remained the same (18 percent). A 2006 NawaLife study 10 shows substantial higher condom coverage rates 7 Progress Report in the Third Medium Plan on HIV/AIDS for the Period April 2004 March DSP, MoHSS. 8 Turning the Tide: Reducing HIV Infection Among Young People, 2007, UNICEF 9 Results of the 2006 National Sentinel Survey Among Pregnant Women, Press Release, MoHSS 10 HIV/AIDS Strategic Information Report : Lifestyles, Knowledge, Attitudes and Practices A Mid Term Household Analysis of Residents from Keetmanshoop, Oshakati, Rundu and Walvisbay. May Nawa Life 29

30 in the year age than in older age groups. The same study also showed an increase in the number of young people having multiple sexual partners and that having multiple sexual partners was linked to self-esteem and concepts of manhood. The study also indicated that the age at first sex continues to decline, but this is not corroborated by the latest Demographic and Health Survey (DHS) 2006 data. Key issues Life skills School participation in My Futures is My Choice and Window of Hope varies substantially per region. Although a considerable number of schools participate in the programmes, the actual number of children reached may well be below 10 percent of all learners per year. Many learners think: I know everything Only 30 learners can participate in about HIV already, no need to sign up WOH and 20 learners in MFMC per (Boy grade 12) training; while the same children may join the training over a number of years, the majority of schools make no efforts to encourage OVC to participate in the programmes; some teachers/facilitators skip modules which address more sensitive issues such as sexuality and condom use; and a substantial number of schools do not complete all 4 windows of WOH junior. 11 While the Ministry of Education (MoE) has taken over the full responsibility for WOH and MFMC, UNICEF will still fund part of the programme until A review to look into what changes are required, including possible integration of (part of) the programmes into the regular school curriculum, would be very timely. Several NGOs are also working on life skills manuals for use in schools without this being coordinated by the MoE. Teachers responsible for life skills subjects in school are not adequately trained. A training module for teacher training institutes has been prepared to address this issue. However, the teachers in the training institutes in turn would need to be properly trained because life skills training requires a facilitation instead of a teaching approach. The teachers are there for life skills but they are not building life skills they need to be trained and supervised otherwise the integration will not happen. There seem to be some school safety issues in general, i.e. anecdotal information points to the fact that sexual harassment from teachers to students is not uncommon. Students in Caprivi furthermore report to be vulnerable to unwanted sexual encounters in periods of flood when the schools become the refuge for students. Some students have also been dismissed from school because they were believed to be involved in a relationship with a Sugar Daddy, while this was actually not the case. The DHS 2006 preliminary data show that the higher the educational background, the better people are informed about means of protection, i.e. 71 percent of women with no education versus 95 percent of women with higher education know that limiting sexual intercourse to one uninfected partner can reduce one s HIV risk. In relation to condom use this varies from 64 percent of women with no education to 91 percent of women with a higher education. 12. However, the existing education structure results in high drop out of secondary schools especially in grade 10. Many of these school dropouts become unemployed. The 2007 NawaLife study 13 links 11 HIV and AIDS Knowledge, Attitudes, Practices and Behaviour (KAPB) Study in Namibia, November 2006, UNICEF 12 DHS preliminary 2006 data, June HIV/AIDS Strategic Information Report : Lifestyles, Knowledge, Attitudes and Practices A Mid Term Household Analysis of Residents from Keetmanshoop, Oshakati, Rundu and Walvisbay. May Nawa Life 30

31 youth unemployment with increasing levels of alcohol consumption in turn leading to strong increases in risk behaviour. Youth in general In spite of the high levels of HIV knowledge, large numbers of young men and women continue to have unprotected sex, multiple sex partners and low levels of self-risk perception. People continue to think HIV is a problem of others. If people feel they are not at risk, why would they need to change their behaviour? Some promising small scale training initiatives in Namibia such as AIDS and me developed by IBIS that address selfrisk assessments and involves people living with HIV, could possibly be scaled up to address this issue. Critical to this would be that enough capable facilitators could be made available in the years to come. Many interventions fail to address sex and sexuality issues in a thorough fashion, e.g. the risk of anal sex in both male-to-male and female-to-male sex is only mentioned in few education materials and not addressed in face-to-face/peer education programmes. Traditional and modern cultural believes and practices in relation to sex and sexuality, concepts of manhood and self-esteem are not addressed either. Furthermore, practical strategies to reduce the influence of alcohol on unsafe sexual behaviour and to reduce forced sex and rape have yet to be worked out. Currently more female youth than male youth participate in all kinds of BCC activities. We could do an awful lot more to link prevention with testing. We are missing the opportunity to reinforce prevention among people who have tested positive. And not much is done with people who tested negative except within the post test counselling sessions. Especially with repeat testers, we need to do more to unpack the reasons why they continue to come back for testing. The links between behavioural change activities for young people and other prevention components such as STI management, PEP after rape, Voluntary Counselling and Testing are usually weak. Many peer education and face-to-face communication activities only interface one to three times with a person. This is simply not enough to build the motivation and skills for safer sexual practices. The previous strategy of having a youth peer educator stay at the health facility to make the facility more youth friendly is now being replaced by efforts to make all staff more youth friendly through facility based training. For this purpose a manual is being developed. Youth employment programmes and income generation activities for youth are limited both in term of availability and in choice. Most youth centres only provide computer, tailoring and gardening courses. Cross fertilization between these programmes and HIV BCC activities also needs to be strengthened. Recommendations Life skills Review the WOH and MFMC programmes and see how the programmes can be truly institutionalised within the MoE and continue beyond Strengthen the supervisory system to ensure that i) sensitive sessions are not skipped; ii) different children, including OVC, are enrolled every year; iii) skills 31

32 are really being built as result of the trainings and; iv) technical assistance can be made available where necessary. Make the programmes more attractive for older learners and for boys in general through piloting boys only sessions, including sport activities, and showing soap edutainment videos. Strengthen advocacy efforts in the community to build an environment where young people can put into practice what they have learned and involve people living with HIV in the programme. Develop participatory training materials to support the training and the AIDS Awareness clubs and ensure that teachers develop facilitation skills. Make the subject life skills in the formal school curriculum examinable. Coordinate the different life skills activities of other NGOs and ensure they complement one another. Develop and/or enhance a school harassment policy and ensure its implementation. Restructuring of the education system, allowing youth to repeat exams at grade 10 and providing more options, including on vocational training, would be an important step to turn the tide. It could help boys and girls to stay longer in school and to have more job options once they are finished. Youth in general The research on epidemic dynamics, mentioned in previous sub-sections of this chapter, should also look at behavioural change among youth and develop a system that will facilitate understanding trends over time and guide evidencebased programming for young people. Undertake research looking into sexuality, including traditional beliefs and practices, sexual networks, perceptions in relation to condom use, forced sex, etc. and develop BCC materials/approaches based on the research results. Undertake research to better understand why male youth/men feel that HIV and AIDS is something for women, and what aspirations/desires could really motivate boys/men to adapt safer behaviours. Pilot and document approaches through which boys/males will become more interested in becoming part of the response. Build capacity and participatory support materials to facilitate on the ground faceto-face communication for behavioural change addressing sexuality, violence, alcohol use, self-risk perception, condom negotiation, Sugar Daddies, etc. and ensure special targeting of young males. Develop guidelines for existing mass media products (such as the Take Control Campaign focusing on safer and better relationships addressing alcohol use, gender and care and support) for on the ground BCC. Review the effectiveness of TV, radio messages/spots/magazines for youth and how these media can be used in such a way that they complement face-to-face communication instead of causing an AIDS fatigue Ensure that STI management and PEP (for rape cases) become standard components of BCC interventions Once you have a media campaign, it does not filter through to the communities. We need a communication strategy identifying partners in the field through which filtering down can be ensured The minds of youth are glazed over with HIV Organize facility based youth friendly training for STI, VCT, PMTCT, treatment facilities that involve youth as facilitators and monitor whether what has been learned is being put into practice. 32

33 Develop linkages between vocational training/income generation programmes for youth and HIV/AIDS behavioural change communication interventions. Emerging Issues Alcohol abuse remains a big problem. There are some regulations that try to limit alcohol sales, but these are currently not or hardly reinforced. Anecdotal evidence indicates that drugs which facilitate sexual assaults, the socalled rape drugs such as Gamma Hydroxybutyric Acid (GHB), Rohypnol and Ketamine, are also increasingly being used among young people. This means that more attention needs to be given to building awareness and skills on how to avoid being drugged with these type of substances in youth behavioural change programmes. 33

34 Sub-component 2.4.1: Social Mobilization and Awareness Expected outcomes: Reach 100 percent of the general population with social mobilization and well targeted awareness interventions; and empower people so that they want to and are able to protect themselves from HIV infection. Progress and Achievements Social mobilization has been an integral part of the AIDS Control Programme since its inception in the early 1990s. It was a building block for sensitizing the general public on AIDS and also included specifically targeted messages for groups at risk. Namibia currently has adopted a holistic approach to social mobilization and involves public, civil society and private sector partners. DHS data indicates that the national response has contributed an increase in HIV/AIDS awareness amongst the general population from 89 percent in to 99 percent in 2006 (preliminary results). The percentage of people who know how to protect themselves from HIV in general is high but less people in rural than urban areas know how to do so, i.e. 90 percent of men in urban areas know that condoms can protect against HIV, versus 85 percent of men in rural areas. To achieve the expected outcomes, MTP III proposed a total of nine activities, to be implemented primarily by the Ministries of Broadcasting, Health and Social Services, and Basic Education plus the Take Control Task Force in association with RACOCs and Constituency AIDS Coordinating Committees (CACOC) among others. All nine activities listed in the MTP III have been addressed and form part of an AIDS awareness strategy to disseminate information. The activities have had most impact in the urban areas and have not yet been fully extended to the rural areas. A few church and community leaders have started to openly admit their HIV status suggesting a slight reduction in stigma. Civil society (Red Cross, Nawa Life, DAPP, etc) have begun working in the rural areas, generating community support for HIV prevention and distributing condoms. An interesting example is the Take Control against the Epidemic Campaign (TCE) of the NGO DAPP. Through this campaign, DAPP currently targets 900,000 people - nearly half of the total population - of whom large numbers live in rural areas. For many communities this is the first contact informing them of AIDS and how to protect themselves against HIV. The number of pregnant women knowing their HIV status has increased. Odongwa clinic reports the number of pregnant women with known status was 2,851 in 2005 or 68 percentof total deliveries. This percentage increased to 89 percent (3,918 women) in Key issues and challenges The percentage of men who said to have had higher-risk relationships in the past 12 months was 64 percent in rural areas versus 57 percent in urban areas, while condom use at last sex was higher in urban (79 percent) than in rural areas (67percent). 15 DHS preliminary 2006 data also show large variations in condom use, knowledge levels, levels of risk-behaviour and coverage of testing in the various 14 Namibia Demographic and Health Survey 2000, Ministry of Health and Social Services, Government of the Republic of Namibia 15 DHS 2006, June 2007 preliminary results 34

35 regions. These findings corroborate reports by some NGOs that communities in the very rural/remote areas of the regions are still not covered by HIV/AIDS interventions. The process of empowering people, or creating a change in behaviour to protect themselves, has not yet resulted in substantial levels of risk reduction. Attempts at BCC interventions have been difficult to initiate for a number of reasons including: insufficient information on the community and how to approach them; barriers to changing behaviour that include a casual sex culture; very poor male involvement and attitudes to acting responsibly; and a lack of trained communicators to design and execute BCC programmes. Behavioural change is the only way to stop the spread of HIV until we have a vaccine. The introduction of Smile, the public sector FREE condom, has instilled an ownership and pride amongst Namibian condom users. It has also begun to displace a very popular, affordable male condom Cool Ryder from the market. This is dangerous for a number of reasons: (1) It puts a heavy cost and responsibility on the Government to continue buying condoms, plus maintaining and testing for quality and; (2) It adds an additional burden, and cost, for distribution, storage and monitoring of a product/programme that is not sustainable. The Namibian market is segmented well enough for three types of condoms commercial brands for the up market consumer; social marketed (Cool Ryder) condoms that are affordable and accessible and; Smile for those who cannot afford to buy a condom. Other key concerns surrounding condoms are: (a) there is still not a clear understanding of the actual condom demand; (b) reliable research on correct and consistent condom use or male involvement is lacking; (c) most importantly there is still not a strategy on condom distribution, which would include Smile, the socially marketed condoms (namely Cool Ryder) and the commercial, private sector brands. Recommendations 16 Scale-up intensive IEC campaigns in the relevant local languages, and continue these until 2008, for the rural areas that have received limited or no coverage. This includes an element of Inter-Personal Communications (IPC), where one to one contact with household members is made. In the urban areas generic IEC materials on transmission, condom use and testing should be continued until the end of 2007 and then reduced and replaced with BCC mass media messages and interpersonal communication that emphasize PMTCT, VCT etc. as stepping stones to changing behaviour. BCC campaigns require good communicators to be identified and/or trained. This is especially critical because MIB has informed the MTP III review consultant that their ministry would not be involved with BCC and it was up to the civil society to undertake these activities Include condom demonstrations in rural IEC interventions and supply male condoms (Smile) which can be distributed to the community. Condoms should also be accessible in outlets and public places. For the IEC campaigns it is suggested to use primarily print materials (leaflets and posters) with distribution managed by the OoP and in collaboration with different line ministries and NGOs (DAPP, Red Cross, Nawalife among others). 16 Recommendations to address larger male involvement have not been repeated in this section and can be found in section 2.5. Addressing vulnerability based on gender inequality, violence and alcohol abuse. 35

36 Undertake very soon the surveys and studies that will cover condom demand, and correct and consistent condom use. These findings will better identify the actual condom needs, indicate acceptance and use of condoms, suggest ways to promote male involvement and behavioural change, improve the distribution/outlet network and provide a solid basis for developing a national condom strategy. Intensify Smile condom distribution to more public sectors outlets and expand the Smile promotions and condom availability to the rural areas. The MoHSS should ensure continued availability and accessibility of Smile condoms to all who wish to use a condom. Independent testing and consumer satisfaction surveys could be undertaken to maintain the quality of the Smile condom to international standards. The MoHSS and other donors should also continue their support and funding of social marketing programmes for private sector distribution. Namibia has a national social marketing organisation that has built a local capacity and operates successfully in all parts of the country. Restrict distribution of Smile condoms to only public sector facilities, including hospitals, office buildings and other non-commercial outlets where socially marketed and commercial brands cannot be sold. Smile should not be made freely available in private sector outlets. Undertake more research on beliefs in relation to sexuality, self-risk perception, alcohol and substance abuse, concepts of manhood, values, etc and translate into behavioural change communication messages and approaches for specific sub-populations, for specific regions. Continue with special event days, including World AIDS Day, and coupled with the increased BCC messages, the various condom advertisements and frequent commercials this should serve as a sufficient reminder that AIDS is still with us. With the proposed rolling out of testing services and increased accessibility to VCT facilities, intensify BCC initiatives based on knowing your status and especially target men. Posters and radio spots encouraging testing is seen as an effective and cost efficient media for promoting testing. Messages to encourage testing should include the benefits of anti-retroviral therapy (ART) indicating your health will be improved and the drugs will give you a better quality of life. So knowing your status is important. People living positively could and should be used to promote testing and behaviour change. Testimonials by PLWHA could be given at special events, condom promotions, World AIDS Day activities and for other advocacy events. (Rundu New Start and Otjiwarango municipal support groups have volunteered to serve in such events) Continue distribution of the current posters (You can hug, or You can shake hands etc) and leaflets that are educating the general population about stigma and discrimination. Develop new messages, including materials that are printed in all languages, which further inform the general population on how to live with people who are living positively. Within the last year or so more programme initiatives (DAPP, Nawalife) have focused on the rural communities and have put more effort into generating community support (CAFs and TCE) in the fight against AIDS. Other civil society groups should be motivated to take up this approach. Two existing Namibian organizations that are already established and operating Namibia Planned Parenthood Association (NAPPA) and NaSoMa could also be instrumental in the activities of reaching the communities. In addition to delivering AIDS messages these two organizations would bring additional support to the IPC approach by providing the ways/products to protect themselves (male and female condoms) and other reproductive health information and services. The rural and community focus is necessary to move the AIDS prevention programme forward.. 36

37 Sub-component Workplace Programmes Expected outcome: 90 percent of enterprises and all line ministries have expanded behaviour change interventions in the workplace linking prevention, treatment, and care and support in place 17. The lead agency for most activities is the Office of the Prime Minister. Activities prioritised include establishing management and coordination mechanisms to support workplace programmes in the public and private sectors; developing training and toolkits for WPP; developing a comprehensive monitoring and evaluation system; and the development of strategies to access treatment for workers. Progress and achievements: The national Code on HIV/AIDS in Employment (drafted by the Ministry of Labour in collaboration with Ministry of Health and Social Services) published in 1998, is referred to by a majority of stakeholders and is used as a basis for designing and defining HIV/AIDS workplace responses. The code provides a good frame for a non-discriminating workplace environment in line with national systems. Medical aid schemes catering for civil servants also provide for HIV/AIDS care as part of the package. Only a limited number of employees belong to a medical aid scheme,.however, treatment is largely available in the public sector. At least 60 private companies implement HIV/AIDS workplace programmes, one line ministry implements a comprehensive workplace programme, and three others have prevention, care and support programmes. Key issues and challenges: Except for the National Planning Commission in the Office of the President, none of the ministries have finalised or endorsed the HIV/AIDS workplace policy. In the absence of national HIV/AIDS policy, the HIV/AIDS workplace policy has been left at a draft level in most of the ministries, who report they are waiting for the national policy. The national HIV/AIDS policy was only approved in March 2007, and has not yet been launched. Of the registered employers in the country, only 62 reportedly have HIV workplace programmes. The National AIDS Business Coalition against AIDS (NABCO), NANASO, NaSoMa, who all have HIV/AIDS workplace activities in their work plans, have so far not been able to expand the roll out of workplace programmes with the urgency it requires. Implementation of workplace responses is largely ad hoc with little or no budget, coordinated by a focal person who is unclear about what is expected, and not linked to the HR unit. The common and sole activity implemented is condom distribution and observation of WAD and other events. Also notable, even in departments where a higher HIV/AIDS response is reported, such as in the Ministry of Education, implementation at regional level is low or invisible. Recommendations: Prioritise the drafting of a Public sector HIV/AIDS workplace policy guideline to be used as a reference point for all ministries, offices and regions in the development of their workplace programme, and also a basis for monitoring HIV/AIDS workplace response in ministries. Make technical assistance available to guide practical implementation to all ministries and organisations. 17 The strategic result for prevention, a section within which workplace programmes fall under, is reduced new infections of HIV and other STIs. 37

38 Strengthen the Office of the Prime Minister to play its role effectively in the coordination, support and supervision of the public sector in the development and implementation of the HIV workplace programme. Ensure that HIV/AIDS in the workplace activities are more comprehensively included in the regular workplace inspections by the Ministry of Labour. 38

39 Sub-component 2.4.3: Expand Condom Provision Expected outcomes: Increased condom use amongst sexually active men and women aged by 51 percent; condom use is openly promoted through a variety of channels Progress and achievements The MTP III identified a total of 12 activities for this sub-component that ranged from policy development to research. The MoHSS was the lead partner in ten of these activities and have fully met their commitment by completing all tasks. In some activities condom distribution and condom logistics the MoHSS excelled in the implementation. The gaps in this sub-component continue to be knowledge around who uses condoms and in some cases youth friendly facilities have not been established in all public sector facilities as yet. The MoHSS has achieved a remarkable success in getting the big C word out in the open and to a point where condoms can be openly discussed, talked about and promoted within all segments of the population. Several billboards, advertising and promoting the use of condoms for protection against HIV can be seen throughout the larger cities and regional urban areas. Adverts providing information on condoms, both male and female, and linking condom use to protection against HIV, are placed at bus stops, in various shops in the market place, in health facilities and in public buildings. Mass media radio and TV spots on AIDS and condom use are frequent, with many messages targeted to young people. Public sector supply has been increased through local production capacity. The introduction of Smile condoms for free distribution and the continued improvement in the packaging and distribution network has helped fill the condom gap. Smile has provided an alternative brand and an additional choice for those wishing to use a male condom. With the availability of Smile condoms in the private and commercial sector this will further strengthen the accessibility to potential condom users and make them available when a condom is needed. Because of Smile s popularity there will be a knock-on effect for other condom brands. This should increase overall condom use and enhance the chances of more men accepting condoms. Total number of male condoms distributed in 2006 from the two social marketing organizations was over 4 million pieces. Figures for Smile could not be verified but are reported to be over 17,100,000 pieces in 2005/06 and over 23,200,000 in 2006/07. Likewise distribution for NAPPA condom figures could not be verified but are estimated to be less then 300,000 pieces per year. The appointment of a condom logistics officer in Otjozondjupa Region is a very positive step forward. This will not only facilitate condom distribution, but also improve coordination, assist in identifying condom demand and sexual lifestyles (number of rounds/sexual partners). This feedback will provide solid information for preparing behavioural change interventions. Key issues and challenges In the year 2005/06 approximately 18 to 21 million male condoms were distributed by both the public and private sector. However there is very little reliable data to show that condoms are always used correctly and consistently. There is also no good understanding of the how many millions should be made available per year to cover the actual demand. With a very popular free condom, Smile, the MoHSS must determine if the product is generating new condom users, or is there only brand 39

40 switching from Cool Ryder or other brands. With a very attractive packaging cross border marketing/distribution of both Smile and Cool Ryder is a very distinct possibility. Monitoring of sales and distributors must be undertaking on a monthly basis. The Global Fund is proposing a national condom needs assessment survey in This survey is encouraged by the review team. However, as a condom is a personal item and reported use by an individual hard to verify, any information received will have to be judged with these factors in mind. NaSoMa, the major distributor of the female condom (Femidom) reported sales of 183,775 pieces countrywide in 2005/06. This includes the sales of female condoms to MoHSS and others for demonstration and promotion purposes. Health workers and some VCT staff have indicated that there are many requests for female condoms, but this has so far not translated into a demand for the product. It is said that the inner ring of female condoms are popular amongst women for making bracelets (bangles) and that people have complained about the difficulty of insertion, the noise during use, and product cost. Condom negotiation remains difficult, even when the HIV status of a partner is known. Many PLWHA have stated that their male partner is reluctant to use any condom (male or female) even when her status is given to him. Recommendations: Urgently determine the actual number of male condoms required in the country so there can be a link established between demand/need and correct use. Several surveys (Gap analysis among others) have been undertaken and the Global Fund is planning to undertake a national condom needs assessment hopefully during Prioritise this Global Fund survey for the MoHSS. A quick calculation using a formula explained in the footnote below, shows that minimal 10,800,000 male condoms would be required each year. 18 In addition to the needs assessment, further studies on sexual practices, conducted on a regional basis, need to be considered. Earlier mini surveys among certain groups, which indicated six rounds a night with multiple partners could be used as a baseline The country is now producing a high quality male condom that has provided some ownership and brand loyalty. Anecdotal evidence suggests that there has been increased acceptance of condoms. This should in turn improve on condom use, but again a study should be undertaken to monitor and evaluate this aspect of the Smile product. With an accepted, locally produced product peer education revolving around the SMILE condom should be initiated to create a positive influence towards male responsibility, built on pride and something Namibian. Undertake surveys, focus group discussions (FGDs) or intercept studies to determine if former Cool Ryder or Maximum Gold users have merely switched 18 One possible formula to consider is: 1) Assuming there are 500,000 very sexually active people (between the ages 18-34), and half of the 500,000 are men (250,000 men). 2) Assuming each man is having sex 3 times a week with 4 rounds per sexual encounter 3 times a week times 4 rounds = 12 rounds (or 12 condoms) required each week. (Could also be calculated as sex 6 times a week with 2 rounds per night) 3) 12 rounds per week times 4 weeks = 48 rounds (condoms) per month. 4) 12 months times 48 rounds (condoms) = 576 condoms required each month per man. 5) 576 condoms times 250,000 men = 14,400,000 condoms per year assuming 100% condom use with each sexual encounter. 6) We know condoms are not used every time, but let s say 70% of the time 7) 70% of 14,400,000 is 10,800,000 pieces minimum are required each year. 40

41 over to Smile, and if so, why (quality, cost, accessibility) or if indeed the pride of a good quality Namibian product has convinced them to use a condom for the first time and they choose Smile. More regular monitoring of sales outlets and distributors should be initiated to stem the outflow of condoms to neighbouring countries. There needs to be a better communication link between sales and condom use. Intercept studies and retail audits should be conducted in all major markets and towns. This will provide some reliable data on condom preferences, affordability and indications on what encouraged condom use Male condoms still remain the most economical and readily available tool for preventing the spread of HIV. Marketing, distribution and promotion of male condoms should continue, with efforts on: increasing accessibility, maintaining product quality, especially of Smile and; the targeting of men for improved consistent use of condoms. Correct condom use is an educational exercise. Using a condom with every sexual encounter is a change in behaviour. IEC messages should be designed to encourage condom use and to make condom use the norm. BCC messages should promote the why to use a condom, based on knowledge, desire and intention. With the introduction of the popular and well accepted Smile condom more promotional messages targeting men to always keep a Smile when having sex or every special moment deserves a Smile should be included in the adverts and promotions. Male involvement and condom negotiation remain gaps in the changing behaviour arena, and both these aspects have an impact on correct condom use. More male targeted BCC is needed and can include messages on sexual relationships and caring. It only takes one time of not using a condom to get infected. To improve behaviour change interventions it is recommended to engage some of the 31,000 VCT clients, who have already been tested, and for them to play a greater role as mentors in promoting male responsibility and consistent condom use. This group could be effective in small community group discussions or could also participate as a mobile visiting troupe to promote testing and counselling at special events, road shows or community gatherings. The MoHSS and their partners have a good understanding of the problems surrounding female condom use and the current strategies should continue for the next two and a half years of the MTP III. To increase use and acceptance of the female condom, better positioning of the product in the sales outlets, should be undertaken. This has proven successful in neighbouring South African countries and in Asia (Myanmar). The positioning of the product requires the support of a culturally sensitive advertisement campaign targeting women and informing men of the product s protective qualities. NaSoMa and partners should look beyond the Femidom product. Currently there are four different female condoms available for AIDS prevention the Female Health Company has developed two different types, PATH has one and Dr. Reddy s final version is now available in India, but is still pending WHO approval. Perhaps the MoHSS and NaSoMA could begin trial marketing studies on these products to determine which contraceptive device is more suitable and acceptable in Namibia. NaSoMA should consider a re-launch of their product with new packaging, improved distribution and supported by an intensive marketing campaign. Finalize the policy on condom distribution to prisoners as soon as possible. Prisoners will not always be prisoners and will eventually enter society again. If they become infected in prison, once released they could infect their partners. 41

42 Sub-component: 2.4.4: STI Management Expected outcome: An 80 percent reduction of STI cases by 2009 per syndrome through strengthened STI management and research at all levels STIs remain a major challenge in the prevention of primary and secondary infections of HIV in Namibia. In 2005/06, STIs ranked eighth among all hospital consultations. There has been a noted increase in the total number of STI cases over the past few years i.e. 79,931 (2204) and 82,725 (2005). Genital ulcer disease seems to have stabilized while Urethral Discharge Syndrome (UDS), Vaginal Discharge Syndrome (VDS) and Pelvic Inflammatory Disease (PID) are on the increase. Syndromic management was introduced in 1995 and the STI guidelines on syndromic management were last revised in Most cases of STI are managed within the public health sector. The capacity of the STI unit has been weak since 2004 but recently (June 2007) an STI manager has been recruited. There are two regional coordinators in each of the regions and one district coordinator per district for all HIV related programmes including STI. The country is currently conducting an STI aetiological study, findings of which are going to guide and inform the planned revision of the STI guidelines. The country is packaging condoms under the brand name Smile to give it a local flavour and make it more acceptable to the users. In 2005, two Trainings of Trainers (TOTs) in syndromic management of STIs and one on behaviour change communication for STI were conducted for all the 13 regions. In 2006, seven of the regions conducted training in syndromic management. In the same year, MoHSS conducted one supportive supervision visit to all regions as part of the health sector response. Key issues and challenges: STI is not being given as much priority compared to HIV as witnessed by insufficient funding for the programme i.e. donors prefer to fund HIV intervention. Regional and district coordinators in charge of all HIV related programmes including STI are overwhelmed and so have a tendency to give priority to HIV related activities compared to STI. The country is using STI guidelines that were last revised in While UNICEF 19 and UNFPA 20 indicate that anal sex is not uncommon, no attention is given to management of anal STIs in the current guidelines. There is also not sufficient funding to support STI training at regional level and standardised training materials do not exist. No drug resistance studies have been conducted recently. Partner notification remains a challenge. There are weak linkages between the STI programme and most NGOs in the country. Development of IEC materials on STI/HIV in local languages for awareness raising and prevention efforts by NGOs and others requires urgent attention. 19 HIV and AIDS Knowledge, Attitudes, Practices and Behaviour (KAPB) Study in Namibia: Key Findings, November 2006, UNICEF 20 Baseline on Sexual and Reproductive Health and HIV/AIDS among Adolescents and Youth, 2002, UNFPA 42

43 There are signs that people increasingly seek diagnosis and treatment for STIs in the private sector. Quality of diagnosis and treatment in these clinics is not known. Recommendations: Prioritize and revamp the STI control programme as prevention of STIs is the cornerstone for the control of HIV and AIDS Revise the 1999 syndromic management guidelines urgently, guided by results from the aetiological study underway and recent evidence-based practices. Also include a section on the management of anal STIs in the guidelines. Develop standardised training materials and incorporate training on STI into existing training programmes i.e. the National Health Training Centre (NHTC) programme, pre-service training programmes, I-TECH training. Also develop a special training session on the management of anal STIs for both public and private health providers. Develop, in collaboration with NGOs and CBOs, IEC/BCC materials in local languages for awareness raising and prevention efforts for STIs (HIV included) Strengthen the linkages between the STI control programme, NGOs and civil societies that play a vital role in community mobilization and advocacy for HIV related activities including STI. Prepare STI kits using the Smile condom. STI kits, containing information on sexually transmitted diseases plus a select number of male condoms, have been social marketed successfully in parts of Africa and Asia. The STI kits were sold to mainly private doctors who would, after examining the client, enclose the appropriate antibiotic, and sell the complete STI kit to the client. Ensure linking of treatment of STI with HIV/AIDS education and VCT. 43

44 Sub-component 2.4.5: Voluntary Counselling and Testing Expected outcomes: Provision of quality VCT services in 45 centres throughout Namibia that are easily accessible to vulnerable groups, young people and the general population. Progress and achievements Testing points can be found at public sector hospitals and in many clinics, plus the private sector. Public sector testing points number around 246. The VCT testing facilities are available at most notably the SMA operated New Start Centres (16 centres countrywide), which are operated under a franchise agreement by Faith Based Organisations and NGOs. Private sector clinics (figures not known) also provide testing services for a fee. Although the client numbers are higher at the VCT centres (due to more promotion/better counselling) it does appear that adequate testing facilities for those living in the urban areas and larger towns, is presently available. However, once again the rural areas are not sufficiently covered, although some of the VCTs have started to roll out testing services to small towns and rural areas. Test results from the hospitals indicate on average a +/- 50 percent positive rate, while persons tested in the VCTs average 20 percent to 25 percent HIV positive status. Recent figures from New Start indicate that 2 percent of the previously negative clients are now testing positive. Figures from New Start also indicate that currently one out of five is a repeat client. The total number of clients tested in 2006 at all New Start Centres is 46,000, up from 15,000 when the centres opened in The total number of people tested could not be calculated as only 5 RACOCs have reported test results. The introduction and use of rapid testing has improved the efficiency of health service personnel, provided quicker test results to the client and is more cost efficient. All hospitals and VCTs visited are using the rapid test and have no difficulties with administering the test or in receiving supplies/reagents. The client receives the test results in 15 to 20 minutes and depending on the results appropriate MoHSS protocols are applied, which include further testing and counselling if the client is found to be HIV positive. Smile condoms, and in some facilities female condoms, were available in the testing centres. Information on AIDS was available at most testing centres, usually a leaflet/brochure. Counsellors are in place at the testing facilities, and questions on their counselling techniques were asked, but an evaluation of their counselling skills could not be fully assessed. Codes are used to identify the client and confidentiality does seem to be observed. At two hospitals (Tsumeb and Otjiwarongo) the location of the testing centre in relationship to the other facilities was not convenient to the clients. Of the 14 activities listed under this sub-component three pertain to mobile operations, which have not yet begun. The other 11 activities have been addressed with action being taken on all points. Though the target of establishing 45 centres has not been reached and not all regions have VCT centres. Weak response in Keetmanshoop and Rehoboth has forced the closure (June 2007) of these New Start VCT facilities. Testing numbers are increasing each year at the VCTs. There are several effective posters encouraging people, especially young people to get tested and to know their status. The question is should all citizens be tested (demand testing along the lines of the Botswana or Malawi model) was asked during the regional visits. Most 44

45 objected because of human rights issues and the possible strain placed on the MoHSS to deal with the increased counselling and treatment issues. Key issues and challenges The latest preliminary DHS data show that 51 percent of women and 32 percent of men between year of age sought to know their status. More than half of these women and men (women: 29 percent and men: 18 percent) were tested in the last 12 months, a period during which VCT options have been diversified and training of VCT service providers increased. A comparison between the DHS 2006 and 2000 data shows that while the number of women who has sought to know their status has increased from 24 percent in 2000 to 51 percent in 2006 the number of men doing so has only increased from 25 percent in 2000 to 32 percent in The June 2006 preliminary data also report that more women and men in urban areas (women 60 percentand men 43 percent) went for testing than women and men in rural areas (women 43percent and men 22 percent). Data from the New Start VCT centres 21 corroborate with the finding that women seek to know their status in larger numbers than men. Of the total number of over 96,000 people tested between February 2003 and March 2007 by these centres, approximately 59,000 were women and 37,000 men. Of these women, 26 percent was found to be HIV positive, against 22 percent of men. The above again demonstrates that women are more at the forefront of fighting the epidemic and the need to motivate more men to go for testing. The above also indicates a need to increase VCT promotion and accessibility in rural areas. Another key issue is that of post test counselling for HIV negative results. The large number of repeat VCT clients could point to the fact that after having been tested, people do continue to engage in risk-behaviour. Recommendations: Testing should continue to be heavily promoted as still 49 percent of women and 68 percent of men between year of age (preliminary DHS 2006 data) do not know their HIV status. VCT clients, especially male clients, can be used in promotions that encourage testing and they should be involved in the design of BCC campaigns. Testing facilities must be rolled out to reach the more rural and remote areas, in all regions. This could be an outreach initiative from the existing static clinics/vct facilities. One NGO proposed beginning mobile testing operations/services (activity # 4 of this sub-component), to reach the more remote populations, but an earlier proposal for mobile testing facilities was turned down by the MoHSS. Perhaps this proposal could be revisited. NGOs operating VCTs must be instructed to better document and differentiate between the number of new clients and those who are coming back again for repeat visits. Many of the statistics being reported give only a cumulative number making it difficult to know how many new people are coming forward for testing. Other indicators should be established for measuring VCT centres, that would include infections averted. Strengthen post test counselling and develop specific activities for clients who test HIV negative to strengthen prevention efforts among this group. Studies in other countries indicate that VCT does not always bring about a change in behavior or increase in condom use. Some studies linking information/education on testing and behavior change would be useful more efficient future BCC activities. 21 Prevalence of new clients tested for HIV for the period February 2003 May

46 Sub-component 2.4.6: Safety of Blood Transfusion Products Expected outcome: Continued safety of blood transfusion products and the rational use of these products. The Namibia Blood Transfusion Services (NAMBTS) is a non-profit organization that was established in Its mandate is to provide all blood and blood products and related services in the country. NAMBTS follows the Standards for the Practice of Blood Transfusion in South Africa guidelines for blood transfusion processes (collecting of blood, processing of blood, testing, storage and distribution of blood). NAMBTS has its head quarters in Windhoek and has two satellite centres in Oshakati and Swakopmund. The NAMBTS has continued to routinely test all donated blood for Transfusion Transmissible Infections (TTIs) such as HIV 1 and 2; Hepatitis B and C and Syphilis before it is released into the blood bank. The donated blood is being screened in South Africa using a new technique; the Nucleic Acid Test (NAT) and this makes blood products much safer as the window period is minimized i.e. reduced from 14 days to five to seven days. NAMBTS opened the second satellite blood bank and clinic at Swakopmund in Compatibility testing has been strengthened at all NAMBTS blood banks through introduction of improved cross match procedures. A quality policy has been developed for handling blood collected from different settings e.g. malarious areas NAMBTS managed to procure a state of the art Aphaeresis machine that is used for collection of platelets. This machine makes it possible to collect platelets from one donor only instead of several donors as was the system before making the product much safer. Ten schools have been recruited and are now donating blood on a regular basis, bringing the total number of donating schools from 52 in 2004 to 62 in National guidelines on the use of blood have been disseminated (June 2006) together with a training strategy. Five workshops on use of blood and blood products were conducted and 110 doctors, nurses and laboratory personnel have been trained. Key issues and challenges: The Council/ Board of directors of NAMBTS is comprised of blood donors only and MoHSS is not represented on the council. There is no formalized working agreement between NAMBTS, NIP and MoHSS, who are the major players in the national blood programme. Only nine of 25 facilities providing blood transfusion services have the capacity to fully cross-match blood. There is therefore wastage of blood as there is too much reliance on use of group O blood. Challenges with donor screening, donor education, donor counselling for HIV and donor retention still existing although efforts are being made to address some of them e.g. HIV counselling of donors. Many health facilities in the country have inadequate storage space for banked blood, and continue to use regular refrigerators for blood storage hence compromising the cold chain procedures. Currently the NIP owns most of the laboratories in the country and stores blood for health facilities but staff throughout the country still need training in proper handling of banked blood. Adverse events after transfusion are not being reported to the NBTS and thus haemo- vigilance requires improved monitoring. 46

47 Testing for TTIs using Nucleic Acid Testing (NAT) is currently being conducted in South Africa. Recommendations: MOHSS and other parties should be represented on the Executive Committee of NAMBTS and for MoHSS to assume a regulatory role for the blood transfusion services. Develop a formalized working agreement between NAMBTS, NIP and MoHSS as a matter of urgency for effective and efficient provision of blood services in Namibia. Establish Haemo-vigilance systems. Put in place cold chain and cross matching of blood should be done at all the laboratories to avoid wastage of blood and blood products. 47

48 Sub-component 2.5: Addressing vulnerability based on gender inequality, violence and alcohol abuse Expected outcome: Every region has programmes in place which address gender inequality, cultural practices and alcohol abuse as a means of reducing vulnerability to HIV infection. Progress and achievements The Directorate of the Ministry of Gender Equality and Child Welfare has conducted gender sensitization training in eight regions, which focused on identifying cultural and social values defining gender relations. Five workshops on gender and HIV/AIDS were organized for a total of 360 women and 100 men. Follow up workshops are planned with support from the Global Fund. Training of trainers on female condom promotion took place in the Omaheke and Oshana regions. The Ministry of Gender also worked on building awareness around the Act on Combating Domestic violence through i) training of out of school youth; ii) a 16 day campaign; iii) a National Conference attended by traditional leaders, politicians and representatives from NGOs, CBOs, FBOs and development partners. It is envisioned that this national conference, which is still ongoing, will result in a National Plan of Action to guide government and other stakeholders on activities for gender-based violence. A data base on gender-based violence is being tested. The Ministry of Gender Equality and Child Welfare is in the process of expanding its women and child protection units all over the country. Lastly, the Ministry has also been involved in the promotion of income generating activities for rural women. This is being done on a small scale and could benefit from additional resources. Organizations such as the NGO Sister Nambia, the Namibian Red Cross and Legal Assistance Centre (LAC), also organized a variety of workshops and TOTs on gender and HIV and AIDS. A number of organizations have published magazines which address gender and HIV and AIDS and sexual and reproductive rights. Sister Namibia is developing training materials in various local languages on women s sexual rights based on the field research saw an upsurge in research on gender linked to cultural practices, HIV and law. A major study was carried out by LAC on rape, which provides insight into the nature and magnitude of the problem. Médicos del Mundo (MdM), UNICEF, NawaLife and NaSoMa studies also paid attention to the influence of gender on HIV vulnerability. All studies clearly show that men are the main decision makers when it comes to sex and that women, particularly the young and poor ones, are not empowered to refuse (unprotected) sex. Several organizations are trying to increase the involvement of men in prevention efforts, including PMTCT, and care and treatment services. NawaLife for instance has started with football clubs in the North of Namibia and several other organizations, such as DAPP, are planning to organize similar events in other locations. EngenderHealth is in the process of establishing a Men as Partners Program (MAP). For this a technical assistance plan has been developed and training in various parts of the country scheduled. The MAP trainings aim to result in less women getting infected with HIV, more gender balanced attitudes and lifestyles of both men and women, and women receiving more respect by their male friends and partners. An all male conference is also being scheduled for 2007, which should result in a program of action addressing specific issues with regards to men. 48

49 Key issues and challenges The major mode of HIV transmission in Namibia is through unprotected sex. As mentioned above, men are the main decision makers in relation to sex and the majority women are not empowered to refuse unprotected sex because of poverty, existing cultural and sexual norms, legal frameworks and violence. However, prevention and also care and support programmes in Namibia have largely failed to involve men and to make HIV/ AIDS also a men s issue and a number of attempts to involve men have only very recently started. The unequal gender relations in Namibia manifest themselves in different forms, including differences in access to resources, inheritance structures favouring men, excluding women from decision-making processes and women shouldering the main burden of care and support for the infected and affected. Female-headed households in rural areas are particularly burdened and vulnerable to poverty and HIV/ AIDS, sometimes resulting in sexual exploitation in exchange for goods and security. Implementing partners have difficulties to mainstream gender in their programmes. Most NGOs do not know how to translate research results into practical activities that could empower women and reduce their HIV vulnerability. Overall there is lack of data through which the impact of the epidemic could be monitored from a gender perspective. The sero-surveillance system for instance only focuses on pregnant women and does not include any male sub-population. Output data regarding training and number of people reached is often also not disaggregated by sex Abstinence is frequently campaigned for, but there is no evidence that this prevention effort is effective. In fact, given the current and grave gender imbalances in Namibia, as also mentioned in MTP III, it might well be that especially poor women mostly suffer from such campaigns, as they generally lack the power to negotiate in situations when men want sex. The programme design of MTP III did not address gender in a systematic crosscutting way. The Ministry of Gender Equality and Child Welfare (MoGECW) so far has not been involved enough to ensure that gender is being addressed holistically. The communication flow between MoGECW and MoHSS has also been limited and activities undertaken by MoGECW have not been reflected in MTP III progress reports produced so far. Police records indicate that up to 90 percent of violent crimes in Namibia are alcohol and drug related. The 2006/2007 NawaLife Study shows that there is a high overall pattern of alcohol consumption among youth and adults and that these high levels of alcohol significantly increase HIV-risk behaviours. Recommendations: Strongly support efforts to increase the involvement of men in prevention and care and support activities. The existing experiences from NawaLife, The Rainbow Project, Sister Namibia, the Namibian Red Cross and Lifeline-Childline with male involvement could be documented and shared to encourage others to follow their examples. Develop strategies to involve men that draw on qualities that men find important and focus on making men part of the solution instead of blaming men. Develop BCC materials to support this effort and which are based on research that looks into aspirations and goals of men. Roll out training to facilitate male involvement. 49

50 Discuss whether or not poor women mostly suffer from campaigns for abstinence, given the current and grave gender imbalances in Namibia, as they generally lack the power to negotiate in situations when men want sex,. The most recent HIV prevalence figures indicate that there has been no significant decrease in HIV prevalence rates, revealing that women and girls have not been empowered through the Abstain, Be faithful, use Condoms (ABC) campaigns that have run in Namibia for the past years. Continue with the empowerment training that has been rolled out by organizations such as Sister Namibia, especially targeting rural areas,. Incorporate into prevention efforts attention for Post Exposure Prophylaxis for female and male rape victims. Health and social workers, police and judiciary should be trained to assist these rape victims. Develop, through MoGECW, a gender mainstreaming strategy which could guide programming, implementation and monitoring for MTP III. Incorporate a gender perspective in all parts of the plan to help enhance the effectiveness of HIV prevention and care and treatment. Make outcome indicators more gender sensitive to easier assess the effectiveness of the response. The sero surveillance system should also be expanded to incorporate male subpopulations. Enhance poverty reduction initiatives, especially for poor single female households. Increase activities to address alcohol abuse. The Take Control Campaign respect your partner could possibly be used as basis for further BCC material and activity development on alcohol abuse. Increasing recreational options in We need to involve men in a positive way. The culture to blame men only leads to men feeling cornered and they only become more extreme in their behaviour. communities may also be a useful strategy. Reinforce regulations regarding opening hours of shebeens and bottle shops. Assisting shebeen owners with alternative business development could also be piloted. 50

51 COMPONENT 3: SERVICES ACCESS TO TREATMENT CARE AND SUPPORT Expected Result: Access to cost effective and high quality treatment, care and support services for all people living with, or affected by HIV/AIDS. Considerable progress was made towards achieving access to high quality treatment care and support services in Namibia. Prevention of mother to child transmission (PMTCT) and anti-retroviral treatment (ART) started in Namibia in 2002 and 2003 respectively and were rolled out quickly and effectively to all regions in the country. HIV related services are now available at 44 communicable disease clinics (CDCs) which are located mostly in the bigger towns. At the end of March 2007 over 41,000 patients are recorded as ever having started treatment. The number of people on treatment has exceeded the target set for 2008 by the MTP III and overall targets have since been adjusted upwards. An additional estimated number of 6,000 are treated within the private sector on Medical Aid. Due to the lack of an effective patient cohort monitoring system there is currently no accurate information on outcomes. Latest estimates report at least 33,591 patients (72 percent) being alive and on treatment, 5 percent deaths and 2 percent defaulted. For the remaining 21 percent of patients, outcomes are unknown. The main reasons for defaulting and discontinuing treatment are distance to the clinic, lack of food to take with the medication and side effects to medication. PMTCT is available to about 79 percent of the women that attend an ante natal clinic (ANC). The uptake of testing and enrollment in PMTCT for HIV positive women after counseling is high but delays in receiving test results constrain the effectiveness of the program. Overall it is estimated that between 40 percent and 62 percent of pregnant mothers benefit from a full PMTCT intervention. DNA-PCR results are presently available for 28 percent of the potentially HIV exposed children that received PMTCT, showing a transmission rate of 12 percent in those that received sdnvp compared to 30 percent for mother-baby pairs that did not receive sdnvp. Transmission during the period of breast feeding however might still be substantial as infant formula is currently not a safe option in most parts of the country and little guidance is given to mothers on how to ensure exclusive breastfeeding. Quality of treatment and care in the communicable disease clinics is of a high standard. Guidelines are regularly updated and widely available. Due to general staff shortages in Namibia, CDCs are run to a large extent with foreign medical staff. An additional force of community counselors has helped to reduce the work load of nursing staff and to improve the availability of additional counseling and support services to patients. There has also been substantial progress to improve the integration of health responses targeted to HIV infected persons. Main emphasis and progress has been on implementing an integrated response to HIV and Tuberculosis (TB). Co-infection rates are high with 57 percent of TB patients testing positive for HIV. Tuberculosis control in Namibia has seen major improvements over the past years but outcomes are still less than optimal due to continued high defaulting and possibly due to the increasing presence of resistant strains. This poses a threat to the entire population and to PLWHA in particular. The continuum of care concept for people affected by HIV and AIDS is well understood and reflected by the activities covered by the MTP III. While VCT, 51

52 PMTCT, Highly Active Anti-retroviiral Therapy (HAART) and management of opportunistic infections are implemented through the public or private health systems, home based care (HBC), palliative care, and social and legal support are largely left to a wide variety of CSOs, FBOs and NGOs. The latter constitutes an additional workforce of over 4500 motivated people. There is currently insufficient linking, but attempts towards improving integration of HBC and the formal health sector have recently been initiated. Key issues and challenges: While AIDS treatment is free, and the roll out to all regions has improved access, a number of factors compromise access and use of services for an important number of people. One major factor that influences access and adherence is poverty. Poor patients are often excluded from services due to inability to pay service fees or transport costs. Strongly related and mentioned as the most important factor for discontinuing treatment or non adherence is lack of food to take with the drugs. This has important implications for the risk of drug resistance development. The social ART eligibility criteria, designed to safeguard against drug resistance development, are used more as a means to restrict HAART to those that have optimal chances for adherence, than as a means to identify individual s challenges towards adherence and explore options to overcome these. Other factors influencing access and use of services are stigma, denial and fear for breach of confidentiality. Male involvement in PMTCT remains an important challenge. The need for treatment and care services will continue to increase in the coming years with a projected 140,000 people in need of HAART by Namibia will need to prepare itself for this scenario and for an increasing number of patients in need of second line treatment for HIV and for multi-drug resistant tuberculosis (MDR-TB). Current reliance largely on donor funding is not sustainable and strategies need to be developed to mobilize more local resources. Similarly, sustainability and access is threatened by dependence on expatriate medical staff and a centralized and specialist approach to treatment and care. Task shifting to lower cadre at first level health facilities, stronger links with existing community structures and better use of community based volunteers for treatment follow up and defaulter tracing are amongst the options to be explored. Weak and uncoordinated monitoring systems currently result in a lack of evidence on effectiveness and outcomes of the chosen strategies. Streamlining and improved monitoring and evaluation and implementation of applied research into the quality and effectiveness of PMTCT, HAART and other interventions remains of critical importance to facilitate informed decisions on further strategy development. This is particularly important in regards to creating universal access while preventing development of drug resistance. Emerging issues Rapid scale up of HIV/AIDS services at the hospital level may be negatively influencing service quality for other health services. In planning and implementing HIV/AIDS programs, the MoHSS, international donors, and hospital directors should anticipate and minimize possible negative spillover effects upon other health care services and rather try and let these benefit from the additional input. Full integration of HIV-related and other health services will need to be pursued for future sustainability. 52

53 Sub-component 3.1: Capacity development for the health sector Expected outcome: 100 percent of health care personnel have improved capacity to implement, monitor and supervise case management, using updated guidelines and protocols Progress and achievements National Health Training Centre co-ordinates a number of training centres and is responsible for most of the training of medical personnel in Namibia. A number of pre-service and in-service HIV related trainings are organised.the lack of a computerized database makes it difficult for the MoHSS to track the number of staff that still need training. Emphasis has been on specific HIV/AIDS related trainings. It is not clear, in how far the pre-service training has been fully updated to cover all aspects of HIV/AIDS related knowledge throughout the curriculum. Pre-service training Namibia has no medical school in-country and sends its students abroad. The Namibian secondary education does not fully meet the medical school matriculation requirements, and a special programme of pre-medical training has been put in place. Still not all students that have finished the pre-medical training qualify for admission at medical schools, but an increase in numbers graduating has been achieved. In doctors graduated and 24 are expected for This year there are 20 doing internships, and 114 under-graduate trainees of whom 20 have just started training. Pharmacists are also trained abroad and currently five are doing internships, a further 29 are under training. The training for registered nurses sees an increase in enrolment over the past years. This year 97 completed training, 86 of whom work in the public health sector. Another six hundred nurses are undergoing training at the University of Namibia to become a registered nurse. Training for enrolled nurses is provided through the National Health Training Center (NHTC) 297 finished their training last year and were employed by the ministry. There are close to 700 currently under training, with 325 in the first year and 368 in the second (final) year. In-service training The rapid roll out of HAART, PMTCT and VCT services created a high demand for training of existing medical staff to upgrade their skills. Targets were developed based on a training needs assessment that was done by the NHTC in a one week PMTCT course and an ARV course were developed. According to MoHSS 1034 medical staff have been trained in PMTCT,and around 20 ARV courses have been given over the past 3 years. As a means to reduce the workload of nurses and doctors in HIV service provision, community counsellors are added to the CDC staff. These counsellors receive training in counselling skills through the ministry of health in collaboration with NGO s and FBO s. So far 330 community counsellors are deployed in a total of 204 health facilities. They are also trained to perform rapid HIV testing. To be fully certified for HIV testing the counsellors need to have implemented 50 tests that are cross checked, by a lab under the National Institute for Pathology. 221 health workers and 161 community counsellors have been trained and certified on rapid HIV testing. Other fields of training courses included adherence counselling, couple counselling, and nutrition advise. Medial staff in clinics providing PMTCT are trained to collect dried blood spots for sending blood samples of infants to the NIP for DNA-PCR testing. For most ongoing courses training of trainers takes place to guarantee continuity. and allow decentralised training. All courses include clinical mentoring, but 53

54 it is not clear how much time and effort is spent in this regard. It is likely to be a challenge in most cases given the health staff shortages in most facilities. Volunteer training A great number of community volunteers are trained and re-trained by various organisations to provide home based care, community education and HIV/AIDS awareness raising and social support duties. Training curricula differ amongst the various organizations and a commonly agreed on task description is still lacking. PHC unit started facilitators training programmes for HBC training with the aim to appoint focal persons in each region who can organise training workshops. Three regions have been covered so far. In addition it is the aim to develop a pool of trainers from MoHSS and various NGOs that can be drawn upon for trainings. Standards and guidelines A number of guidelines have recently been updated, such as the guidelines for HAART, PMTCT, TB, VCT. Once updated, they are usually well disseminated and short introductions organised for clinical staff. These briefings are also open for private health staff and according to regional medical directors usually well attended. Key issues and challenges Communicable disease clinics (CDC) are largely staffed with non Namibian health professionals. 90 percent of all doctors in CDCs and an important part of the registered nurses and pharmacists are brought in from elsewhere mostly paid by the US President s Emergency Plan for AIDS Relief (PEPFAR). Integration of donor funded foreign medical staff into the general services within a hospital or health centre remains a challenge. How can we have a pool ward with two general doctors, and then we have three doctors only doing HIV and they go home after their clinic finishes at 11? (a PMO) Despite the additional workforce brought in, serious staff shortages are reported in the health sector as a whole. Data from two regions showed a quarter to a third of the position for nurses and doctors to be vacant. A recent assessment by the MoHSS revealed high attrition rates for various levels of health staff, which is influenced by high rates of illness and death, but also caused by staff leaving the public sector to work for the private sector or NGOs. An in depth assessment of the effects of the AIDS epidemic on the heath workforce has not been carried out yet, but with the current prevalence rates it can be assumed that the effects are important. This is in line with a recent study in Zambia 22 that revealed over 60 percent of health staff were living with emotional exhaustion and burn-out as a result of work load, work and family related emotional stress and having to cope with own infection or fear for infection. Workplace programmes within the health sector in Namibia are insufficiently developed and seem hardly known by the staff. Shifting of responsibilities from doctors to lower cadre such as nurses and beyond has been considered by MoHSS, but the idea has been stalled for the time being. Presently with the assistance of WHO an assessment is being done on roles and tasks and required skills levels. We take care of other people, but do not take care of people working in the Ministry of Health. There seems to be a programme but I do not even know where I should go for counselling (MoHSS staff member) Outcomes of this assessment might facilitate the discussion on task shifting and in the future inform further curriculum development. 22 Dieleman, M. et al. (2007). 'We are also dying like any other people, we are also people': perceptions of the impact of HIV/AIDS on health workers in two districts in Zambia. Health Policy and Planning, 2007 vol 22, Issue 3 54

55 Similarly MoHSS has as yet not considered delegating the responsibilities for antiretroviral (ARV) treatment follow up to the community or home based volunteer level, such as is currently proposed for Tuberculosis treatment under the Global Fund Round V proposal. The AIDS treatment programme could potentially make use of the same group of volunteers. The need is well recognized for a policy framework that outlines registration, management, entitlements and responsibilities of volunteers working with the health and other sectors. In 2006 a country wide assessment was done of the volunteer workforce and their needs, followed by a conference in December Since then the discussion seems to have come to a virtual stand still and attempts to streamline working condition, support and remuneration schemes have failed till to date.. Volunteers are left without legal protection or social security benefits and remuneration and support varies widely between organizations. The situation is further complicated by the fact that volunteers seem to fall under the latest labour act, which potentially raises entitlements that most of the organisations and the government are not prepared to cover. Recommendations: Combine efforts to increase the number of Namibian Doctors, nurses and other medical staffs with increased emphasis on strategies to retain available staff through effective work place policies through supportive supervision, ensuring realistic work load, and through a sufficiently attractive incentives package for hard-to-retain staff working in rural areas Complete the currently planned in depth study to analyse tasks related to HIV/AIDS treatment and care and identify the lowest level at which HIV-related duties can be performed. Describe roles and optimal skills mix for health workers at various levels with an aim of devolving responsibilities to less qualified and less costly professionals Implications for staffing and training should be described. If required, start the process of law and health policy to allow nurses and midwives to provide services previously only offered by doctors. 25. Make better use of the extensive community based volunteer workforce, by linking them to the health sector and delegating An example: Some countries established physician led, nurse-run ART programmes, thus substituting more costly HR [doctors] with less costly HR [mainly nurses, midwives]. In such programmes, physicians play the lead role in assessing people living with HIV/AIDS (PLWHA), initiating or switching therapy, managing serious conditions and supervising staff. (model adopted by Uganda, MSF s programme in Khayelitsha, South Africa, and Malawi s Chiradzulu programme as well as by Partners in Health in Haiti) responsibilities accompanied by adequate equipment and resources. This requires the volunteer policy for remuneration, social and legal support for volunteers to be finalized and implemented. The planned nation-wide involvement of community volunteers in the follow up of TB patients under the Global Fund can be considered as an example and a potential means to bring integrated TB and HIV treatment closer to the communities Finalization and implementation of the computerized human resources information system (HRIS), for monitoring staff turnover, human resource planning and planning of training needs. 23 WHO, A public health approach to antiretroviral therapy: overcoming constraints, This would be similar to the country s TB programme, where physicians are involved in initial treatment and management of complicated cases, and trained nurses do routine monitoring and follow up. See Zimbabwe ARV Programme: Issues and Opportunities for Initiation and Expansion (USAID/JSI, 2002). 25 Rising to the Challenge: Zambia Nurses and Midwives Success Story,

56 Sub-component Laboratory services for HIV/AIDS management Expected outcome: Satisfactory laboratory capacity for monitoring of HIV/AIDS disease management and VCT quality assurance Progress and achievements The Namibia Institute of Pathology (NIP), a state-owned enterprise, provides technical support to HIV/AIDS/TB related laboratory services, both to the private and public health sector. The NIP also has a social responsibility as per the NIP Act and they continue to render quality services in the poor rural population where no profits are realized. NIP s role is to assist in the diagnosis, treatment and control of disease. To that effect the NIP developed a detailed Strategic Plan to address laboratory issue over and above those stated in the MTP III. The technical department was overhauled in 2005 and a comprehensive laboratory information system (Meditech) and automated chemistry, haematology and immunochemistry analysers were installed in most of the laboratories. In 2006 the department introduced HIV DNA polymerase chain reaction (DNA-PCR) testing for HIV infant diagnosis and more than 4,200 infants have benefited. NIP also offers viral load (VL) testing at its laboratory in Windhoek. The NIP now has 36 laboratories countrywide. Thirty- two are within public health facilities and the remainder are commercial. The number of centres able to perform CD4+ T cell counts increased from four to six in Five of the CD4 testing centres are in the North and the sixth is in the central region. A courier system is being used to transfer specimens for CD4 testing to the six laboratories and it takes 48 hours for the patients to get their CD4 results. A national testing algorithm was developed followed by field evaluations in Three testing kits (Determine, Unigold and Hemastrip) were selected for implementation and are now in use. NIP has plans to evaluate other new rapid HIV test kits to add onto the current algorithm. Rapid HIV testing by community counsellors (who are non-health professionals) was approved by the MoHSS in A total of 22 training courses have been conducted and more than 500 people, consisting of health workers, community counsellors and non-government employees have been trained in the HIV rapid testing techniques. The first rapid testing site of the MoHSS was opened in May 2005 and by year end there were 13 testing sites with a total of 6,339 clients benefiting from the services. As for Social Marketing Association (SMA) / New Start, 14 sites and 66 HIV rapid testers were certified. NIP is there to provide quality assurance for all services in particular rapid HIV testing. NIP took samples from the previous ANC surveillance survey for HIV drug resistance threshold and is in the process of finalizing the report. Data are not yet available. Several documents have been developed to guide the HIV rapid test programme in Namibia e.g. The National HIV Rapid Testing Standard Operating Procedure (SOP); Training manual for Rapid testing; HIV Rapid Testing quality guideline; SOPs for preparation of quality control samples and proficiency panels among others. Key issues and challenges: Human resource limitations continue to be a challenge as Namibia does not currently have an institution to train laboratory pathologists and technologists. Most laboratories were constructed years ago and are not tailor-made for HIV and TB diagnostic purposes and hence do not meet the laboratory safety standards. Criteria for accrediting rapid HIV testing sites and testers that was agreed upon by MoHSS and NIP in 2004/5 is rather extensive (50 supervised tests) and now 56

57 hampering progress and is affecting effective provision of services and roll out of testing services, and therefore should be revisited. Communication between MoHSS and parastatals like NIP, NAMBTS etc is not optimal and therefore affecting progress and good collaboration. Lack of funding for the sustainability of NIP is a potential threat for the organisation and this can partially be attributed to the low laboratory tariffs that NIP is charging, late payment of obligations by beneficiaries of laboratory services etc. Non involvement of NIP by other organizations in activities that impinge on provision of laboratory services for monitoring and support of HIV/AIDS/TB services e.g. renovations of laboratories etc. Recommendations: Urgently revise the criteria for accreditation in rapid HIV testing for sites and testers. NIP and MOHSS should work in close collaboration when it comes to renovations and construction of laboratory infrastructure so as to meet the international safety standards. Set up regular fora for players involved in the provision of HIV/AIDS/TB services at managerial level so there is sharing of information for the betterment of patient management. This will go far in addressing the communication challenges that currently exist. 57

58 Sub-component 3.2.2: Procurement and Supplies Expected outcome: Management systems for forecasting, procurement, and supply of essential drugs and commodities are able to meet an expanded HIV/AIDS response. Progress and achievements 26 The public pharmaceutical management system of Namibia is critical to the success of the MTP III plan to scale-up HIV/AIDS activities. Prior to MTP III, challenges in pharmaceutical management in Namibia included lack of personnel, unclear organisational and management structures and procedures, inadequate inventorycontrol management systems, and inadequate dispatch and distribution systems. All these were threats to the ability of the supply system to accommodate the increased load envisaged under the MTP III plan to scale up and expand HIV/AIDS activities. Since the introduction of MTP III, the MoHSS and its development partners have made tremendous strides to improve procurement and distribution of medical supplies. In 2006/07, the Medicines and Related Substances Control Act has been approved by Parliament but has yet to be implemented. The act is an important step to modernizing and strengthening the regulations of pharmaceuticals, as the previous governing legislation on this issue was enacted more than forty years ago. The pooling of government and donor funding for pharmaceuticals through Central Medical Stores (CMS) has led to smooth and effective procurement practices. The establishment of a Pharmaceutical Procurement Committee within MoHSS has provided much needed flexibility with respect to the procurement process. The National Medicines Policies Coordination (NMPC) subdivision of MoHSS was revitalized in 2004 through the employment of a pharmaceutical advisor by the United States Government supported Rational Pharmaceutical Management Plus Project. The NMPC is responsible for monitoring and implementation of the Medicine and Related Substances Act; the promotion of the rational use of medicines; the promotion of the use of generic medicines; and HR development and planning in the pharmaceutical sector. The development of Standard Operating Procedures (SOPs) for dossier management and a registration database has led to significant improvement in the process of reducing the backlog of applications, recording medicines and also in registration processing time. In 2006 alone, 29 new ARVs were registered bringing the total to 74 ARV products. Of this total, 49 products are generics/multi-source ARV medicines. This has increased the availability and accessibility of cheaper ARVs in Namibia. Human resources The NMPC subdivision has made substantial progress in alleviating critical human resource capacity constraints within the pharmaceutical sector. As of February 2007, the NMPC reports that twelve pharmacists and eleven pharmacist assistants in the HIV/AIDS program are currently funded by either PEPFAR or the Global Fund. In addition, the NPMC has recruited management advisors and network administrators. 26 One key limitation of the section is that we were unable to meet with a representative of the Central Medical Stores of the MOHSS. 58

59 Under MTP III, the pharmaceutical human resource capacity has further been strengthened through a wide variety of training programs including: HIV/AIDS Pharmaceutical Management Training on the local adaptation of generic Rational Pharmaceutical Management (RPM) Plus Program (USAID-funded) materials; training of pharmaceutical staff in all regions on the quantification of ARVs and record keeping; training on the ARV Dispensing Tool; and training of senior and middle management staff on the CMS tender module. Inventory management The NMPC has finalized the development of a comprehensive Pharmaceutical Management Information System (PMIS). The aim is to improve the availability and use of information guided decision-making with respect to strategic planning, assessment of health status and needs, pharmaceutical management, health system accountability and resource allocation. The system has been pilot tested in a few regions and training and the official launch of the PMIS is planned this summer. By the end of 2006, the ART dispensing Standard Operating Procedures (SOP) were finalized, with the reporting forms tested in six facilities. A total of 11 facilities received on-site technical support visits. By early 2007, the ART Dispensing Tool (ADT) was established in seven high volume facilities. The tool has allowed these facilities to increase the accuracy of ART monthly reports and has assisted in the generation of daily dispensing patient lists thus tracking patients not turning up for their replenishment appointments. However, at this moment ADT and patient registration systems are not yet sufficiently linked up to provide accurate information on adherence. Anecdotal reports indicated that the ADT tool has helped some of the facilities to reduce dispensing time as well as dispensing errors. By the end of 2006, the implementation plan for the provision of minor equipment to treatment facilities in support to pharmaceutical services was finalized and is currently awaiting approval by the MoHSS. The items to be supplied have been identified and include pharmaceutical storage equipment, computers for the installation of the ART Dispensing Tool (ADT) and other various dispensing aids. Financial Management In 2006, the Central Medicla Stores with support from RPM Plus finalized the SOP for CMS.. 32 CMS staff were trained on these SOPs. The draft Supplier Performance Monitoring tool was developed to assist the CMS to better monitor suppliers. The CMS implemented Quantimed, the ARV quantification tool to be used for quantifying ARV needs. CMS staff have received training to be able to produce national projections for ARV medicines needs for the next two years, and also review the projections on a quarterly basis. Key issues and challenges There are a number of procurement and logistics challenges to scaling up and sustaining HIV/AIDS services: Human resource constraints continue to be a barrier for scaling up and sustaining HAART services, as there are still pharmaceutical staffing shortages, particularly at district hospitals which are manned only by Pharmaceutical Assistants. Katutura reported pharmacist shortage as the most important reason for delays in new patients being enrolled for treatment. In January 2007, 67 pharmacists were in post against an establishment of 130. Very heavy workload for pharmacists and pharmacist assistants may be adversely affecting their ability to provide adequate adherence counselling to 59

60 HIV/AIDS clients. Observations in two hospitals showed little counselling being provided. There are challenges with quantification at facility level. Short term stock-outs of ARVs were reported in seven of the 13 regions at least once during the past three years, mostly in the remote regions. Overstocking has been observed during some of the field visits. The storage space in most hospital pharmacies is inadequate to store the required quantities of medicines. This problem has adversely affected supply chain management. The Medicines and Related Substances Control Act has not yet been implemented, affecting smooth registration of medicines in Namibia. Poor transport has limited the inspectorate s ability to inspect facilities in rural areas. The availability of all pharmaceuticals at Health Centre- and Health Clinic-levels is limited. Currently, the MoHSS reports that only five Health Centres and ten Health Clinics stock drugs distributed by CMS. The unavailability of pharmaceuticals at the centre- and clinic-level may result in incomplete services being provided in most rural areas. Recommendations: MoHSS should prioritize the development of a plan to gradually reduce Namibia s reliance on foreign pharmaceutical personnel for HAART (see 3.1 and 5.1). MoHSS should consider strategies to reduce the workloads of pharmaceutical staff at the hospital level. Revising the practice of refilling ARV prescriptions drugs to every three months rather than every month should be considered. The MOHSS should make progress toward the establishment of formal pharmaceutical posts for donor-supported pharmaceutical staff and strengthening pre-pharmaceutical education programs. The MOHSS should prioritize the development of a plan to gradually reduce Namibia s reliance on external financing of ARV drugs through cost containment and increased local financing from public and private sources. 60

61 Sub-component 3.2.3: Prevention of Mother-To- Child Transmission of HIV Expected outcome: 90 percent of HIV positive pregnant women, their children and partners, have access to PMTCT+ services and receive a complete course of ARV prophylaxis to prevent mother to child transmission. In March 2002, Namibia started implementing PMTCT services at its first two sites, Oshakati and Katarura Hospitals and as of March 2007 the program was introduced in 188 health facilities out of a total of 331 health facilities. This includes all the 34 hospitals, some health centres and clinics. The number of HIV tests done has increased steadily among pregnant women, from 5,500 in fiscal year 2004/05 to 13,629 in fiscal year 2005/06. According to the 2006 DHS 27, the percentage of pregnant women who utilize antenatal care services by a trained provider is high in Namibia (96 percent). According to the Health Information System (HIS) statistics for the year 2006/2007, 79 percent of these visits were in clinics that provide PMTCT services, though important variation exists between regions (from below 40 percent up to 100 percent). 97 percent of the clients at PMTCT sites received pre-test counselling, 91 percent took the HIV test, of which 16 percent were found to be HIV positive. Overall 57 percent received post-test counselling,. Of those women who were found to be HIV positive, CD4 testing was carried out among 61 percent of women, up from 29 percent in 2004/05. Fig XX: Ante Natal PMTCT coverage 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% % of ANC Visits in PMTCT Records FY 2005 % of ANC Visits in PMTCT Records FY % Caprivi Erongo Hardap Karas Kavongo Khomas Kunene Ohangwena Region Omahake Omusati Oshana Oshikoto Otjozondjupa Namibia According to the preliminary findings of 2006 DHS, 81 percent of pregnant women deliver in a health facility, 85 percent of which know their HIV status and again 85 percent of these women has received prophylactic ART. The uptake of nevirapine in babies born to HIV positive women that deliver in a health facility is over 90 percent. Based on the above mentioned data, the effective coverage with full course of PMTCT amongst all Namibian mother-baby pairs is estimated between 40 percent 27 These are preliminary data. The final analysis of the DHS was not yet available at the time of this medium term review. 61

62 and 62 percent depending on whether ANC or maternity data are used for calculation. Fig XX: PMTCT coverage amongst women that deliver in health facilities 100% FY 2004 FY 2005 FY % 80% 70% 60% 50% 40% 30% 20% 10% 0% Known HIV Status ARV Uptake in HIV+ Women ARV Uptake in Babies Women Choosing to Breast Feed Source: MoHSS However, some caution is justified. Recent studies in rural Malawi 28 showed that take-home nevirapine is not always used effectively. While all mothers delivering in health facilities took the nevirapine that they were given at the ANC before delivery, only around half of the mothers who delivered at home took it. None of these mothers brought their child for follow up and testing. The current effective uptake of home based nevirapine in Namibia is not known. Of the 188 facilities offering PMTCT services, only 70 facilities (37 percent) are conducting rapid HIV testing on site. The rest of the facilities take blood samples and send this to the district hospital for HIV testing and ANC women have to wait up to two weeks before they get their results. Concerns were raised that an important number of women will not receive the results of their test before delivery, reducing the effectiveness of the PMTCT program. DNA-PCR test is used to evaluate the HIV status of the infants born to HIV positive mothers. So far 120 Health workers have been trained in collecting dry blood stains (DBS) which are sent to NIP for testing. The coverage has reached 58 facilities by the time of the review. Starting from August 2006 till March 2007, over 4,200 infants (28 percent of the estimated HIV-exposed births nationwide) received a first PCR test between the age of six weeks and four months showing HIV transmission of 12 percent in those that received sdnvp compared to 30.4 percent for mother-baby pairs that did not receive sdnvp. The sample is too small and most likely biased towards mothers with better PMTCT coverage to draw conclusions on the effectiveness of the PMTCT program. Further transmission during breastfeeding can be substantial but is not captured by the first test and will need to be measured by follow up tests at 18 months. 28 Kasenga, F. - Hurtig, A.-K. - Emmelin, M. Home deliveries: Implications for adherence to nevirapine in a PMTCT programme in rural Malawi. AIDS Care Volume 19, Issue 5 May 2007, pages

63 Infant and Young Child feeding guidelines were launched, outlining the current policy to advise exclusive breastfeeding during four months with abrupt weaning for HIV exposed babies. The majority of HIV positive women (88 percent) reported their intention to breastfeed compared to 12 percent who opted for replacement feeding. Feeding options after the exclusive breastfeeding period are not clearly defined and breast feeding counselling is reported to be limited. A worrying finding in the 2006 Demographic and Health Survey (DHS) is that around half of the breastfeeding women reported to combine breastfeeding with other foods in the first four months. This increases the child s risk to be infected. Key issues and challenges: Access to full PMTCT services with on-site rapid testing is still limited especially in rural areas. The turn around period of two weeks for HIV tests leads to an important proportion of the mothers not receiving their final test results (on time) and missed opportunities for PMTCT. The effectiveness of the PMTCT program is currently not measured and mechanisms to follow up of mother/baby pairs are still weak. Most facilities do not have registers in place for postnatal care or follow up of babies after birth and it is likely that a substantial number of infected children will not be diagnosed until they show first signs of illness. The high infant mortality rates found in the 2006 DHS are worrying in this regard. Male involvement in PMTCT is still low in the country and insufficiently pursued. One interviewee commented that nothing much is happening in terms of trying to encourage men to be involved in PMTCT except provision of IEC materials. There is currently no active strategy in place to involve community level birth attendants in the delivery and use of nevirapine for mother and child. The current infant feeding policy and advice is based on the observation that formula feeding is too expensive and hygienic circumstances too risky. There are signs though that breastfeeding is not fully exclusive and availability of infant feeding options after exclusive breastfeeding are limited. This is likely to contribute to young children running unnecessary risk for both HIV infection and of exposure to malnutrition and diarrhoeal disease. There is an urgent need to get more insight in effectiveness of current policies and strategies. Recommendations: Expedite the scaling up of PMTCT services to all 331 health facilities in the country offering ANC services including on-site rapid testing services. This will result in pregnant women being able to access their HIV results on the same day and to enrol in PMTCT if indicated. There is need to standardize the training curriculum and materials and have them widely distributed to the different stakeholders conducting training. Workout mechanisms for efficient follow up of mother baby pair and linking them with ART facilities and maternal and child health (MCH) services Need for the national programme to come up with AFASS (acceptable, feasible, affordable, sustainable and safe) infant feeding options after the period of exclusive breastfeeding given the current situation of food insecurity. Develop strategies to involve the communities in all HIV/AIDS/TB programmes as they are essential in providing support to the HIV infected mother such as effective use of take-home nevirapine and follow up of mother/baby pair etc for the PMTCT program. The monitoring and research into effectiveness of the current PMTCT strategies (use of take-home nevirapine, follow up and testing of babies after delivery, infant feeding strategies) is much needed to provide evidence and to inform and guide programme management. 63

64 Sub-component 3.2.4: Management of Opportunistic Infections Expected outcome: Increased access by PLWHA to opportunistic infections prevention, comprehensive case management and palliative care. Progress and achievements Namibia has had guidelines for the treatment of opportunistic infections (OIs) in place since These guidelines were reviewed in 2005/2006 and one major policy change in the management of OIs was that all patients with a CD4 count below 300 or WHO Stage III or IV disease were now required to be started on cotrimoxazole prophylaxis therapy (CPT). OI training that used to be a stand alone programme has been integrated into ART since 2005 and the training curriculum has been revised accordingly. All ART facilities also provide CPT. The simplified protocols for the Integrated Management of Adult Illness (IMAI) were planned to be introduced as the cornerstone for HIV chronic care management at sub-district level. The actual implementation and roll out is currently on hold awaiting further approval and guidance by the MoHSS. Palliative care has only recently been given more attention with a first workshop organised with input from the African Palliative Care Association from Uganda. As a result, guidelines for palliative care in Namibia are now worked on by the Primary Health Care (PHC) unit in the MoHSS. Activities to integrate TB and HIV response are described in section Key issues and challenges: Currently limited information is available on the follow up of patients pre-haart and the management of opportunistic infections. Patient data are not reported. Many more health care workers still need to be trained in OI management and IMAI to be able to provide basic HIV/AIDS care at the primary health care level. Information on the number of other sites offering CPT and the total number of patients actually benefiting from CPT was not readily available. Isionazid (INH) prophylactic treatment is included in the Tuberculosis policy and guidelines, but is yet to be implemented on a large scale. Recommendations: Accelerate the roll out of IMAI and continue the process of developing guidelines for palliative care, in light of the MoHSS plans to delegate the role of follow up of patients on OI/ART to nurses. Capture data on the coverage and effectiveness for the different OI prophylactic programmes available e.g. cotrimoxazole, diflucan, INH etc. The new AIDS patient monitoring system is expected to cover this. 64

65 Sub-component 3.2.5: Organisation and integration of services, integrated TB/HIV and Opportunistic infections Expected outcome: PLWHA and PLWTB have access to a continuum of care and support services for TB and HIV/AIDS diagnosis, in all health care facilities and home based care services in public and private sector. Progress and achievements Alongside the roll out of ART treatment, considerable progress has been made towards strengthening the provision of comprehensive care for people living with HIV AIDS. The 44 communicable disease clinics (CDCs) currently running in the major towns throughout the country encompass all elements of essential medical care for PLWHA. In the other health facilities the organisation of integrated and comprehensive medical care is somewhat more challenging. Most rural facilities are able to provide a variety of services, VCT and PMTCT being amongst the most commonly found, and will rely upon effective referral to CDCs for other services. This system functions for as far as patients are able to afford the transport and time to travel. Mobile treatment outreach, using a visiting doctor to provide consultations and ARV treatment in rural clinics, has been planned for but implementation has been delayed due to lack of adequate facilities and work overload of visiting doctors and nurses. Most CDCs operate as separate departments within the premises of existing hospitals and clinics. This set up provides easy access to HIV positive patients and easier referral to various departments within the services. Though there is a potential risk of too much separation from the rest of the hospital services, staff both from within the CDC and from the rest of the hospitals in most cases report good exchange and mutual support. Patient flow systems seem to be relatively standardized in most CDCs. The various steps in the process from registration through to dispensing of drugs at the pharmacy ads up to a lengthy process with ample waiting time in between each step. It was Some people have to stop treatment because their treatment supporter can no longer come every month for a full day with them, or they loose their job. [ ] It is not easy to find a treatment supporter that can always come with you. They should allow us to come without the treatment supporter once things go well (Home based care provider/ peer supporter in Erongo region) reported that a patient can easily spend a good part of the day in the clinic for his three monthly follow up visit. This creates an additional burden to the treatment supporter who is required to accompany the patient on his/her three monthly visits. The monthly drug dispensing visits are less cumbersome but still perceived as a burden by most patients. PMTCT is often not integrated in the CDCs but usually provided directly by the Ante Natal Care (ANC) services and patients are referred to the CDC either for HAART if the CD4+ count is below 250 or for usual follow up as an HIV positive patient after delivery. Follow up of infants born to HIV positive mothers, especially for those that delivered in rural clinics is not in all situations smooth. This might be one of the reasons for an increase in infant mortality as seems to be a finding of the latest DHS. STI services are usually provided in the normal Out-Patient Department (OPD). No good data is available on effectiveness of the referral to VCT and/or CDC if needed, but anecdotal evidence suggests that referral for VCT is often overlooked. It is suspected that an increasing number of patients with symptoms of STIs visit private 65

66 clinics to avoid HIV counselling and testing, to avoid stigmatization and be offered confidential services. The integration of TB and HIV services is an important element in comprehensive care for HIV positive patients particularly in Namibia (ranking second on the global list of TB prevalence). Co-infection rates are as high as 57 percent (see table 1.1). Table 1.1: Diagnostic HIV testing in new TB patients, (1 st Q) % of new TB cases tested for HIV 16% 30% 44% % of people tested found HIV+ 58% 67% 57% The decrease in reported prevalence is possibly a reflection of previous selection bias towards HIV suspects. The true rate can only be established once almost all TB patients are tested. Vice versa doctors and nurses in the CDCs report screening of all patients for active Tuberculosis using a standard screening format at first registration of an HIV positive patient. The current registration and reporting system for HIV positive patients does not provide accurate data on numbers actually screened or the percentage of HIV positive people that are found to have active Tuberculosis. Isoniazid prophylactic treatment against Tuberculosis for all non-active infected PLWHA, was included in the latest policy and guidelines but is not widely implemented yet. The new registration systems for HIV positive patients (to be rolled out in July 2007) require TB related data to be entered and reported on. At service implementation level most TB and ART services are physically separated and there is anecdotal evidence of patients dropping out when referred between the two clinics. Long waiting time is given as one of the reasons. Introduction of one-stop services is being considered by the MoHSS but the system is not ready yet e.g need for preparation of TB doctors and nurses to be able to manage the co-infection effectively, and upgrading the infrastructure to make the environment safer for HIV positive and TB patients. The programme management and supervision at district, regional and national level will need to be better coordinated and preferably fully integrated. Attempts are made now to combine supervisory visits to the regions. In our programme (OHEP) we were able to bring the tuberculosis defaulter rate down from 51% to 0% and cure rate up from 28% to 91% and case detection form 3% to 71%. This was largely due to the work of community DOTS volunteers. This shows how valuable volunteers are when they are linked to the health services and supervised well. (Omaheke programme) A policy on integration of TB and HIV programmes has been agreed on and a coordination body for TB/HIV collaborative activities was recently established at national level. The first meeting took place in May 2007, where members were designated and four working groups established (infection control, IEC, Advocacy and MDR-TB). Integrated management of adult illnesses (IMAI) as a concept has been accepted and should be rolled out once the policy and/or guidelines are developed and approved. In many regions the private sector provides a substantial part of health services for HIV positive people including the provision of HAART. The staffs at private clinics are usually invited for workshops where new guidelines and protocols are launched and discussed and their turn up is reported to be very high. Once a year doctors are required to renew their licence through the regional medical office. 66

67 Key issues and challenges: Services for HIV positive patients are not organized in a patient friendly manner. Waiting times are too long, monthly visits for medicine distribution and the requirement to bring a treatment supporter along create unnecessary barriers for patients. The set up of communicable disease clinics (CDCs) as separate services within health facilities poses challenges in terms of integration of services and easy referral and flow of patients through the systems. Although in most cases the flow is good, there are signs that referral between TB and HIV clinics and from PMTCT to MCH and CDC for follow up of mother and child sometimes fails. Currently up to six different monitoring systems managed by different departments in MoHSS are in use that allow individual patient monitoring and to track responses of various health related services. Most of these are not linked and important differences are found in data reported (e.g. adherence). Quality check on reported data is minimal and some figures on defaulter and deaths rates might be underestimated. Despite a strong causal linkage between STIs and HIV there is minimal integration in practice because of the weakened STI program (see section 2.4.4). Though an explicit aim in MTP III, the integration of home based care and support responses into existing health care system has not been fully implemented yet (see 3.2.7). To date, there is no reporting obligation by the private sector towards the MoHSS and the only way to get data on their activities is through the health insurance statistics leading to incomplete HIV treatment surveillance data. This also means there is little control over quality of the services provided. The profession is largely self regulatory through the medical councils. In interviews with staff and patients it was suggested that less stringent criteria are followed for inclusion of patients on HAART and in a number of private clinics little effort is made to follow up on patients to monitor adherence to appointments. Recommendations: Develop systems for easier and faster patient flow through the various steps of comprehensive treatment and care services that are part of the routine follow up. Reduction of frequency of follow up visits by providing three months supply to patients on stable treatment is recommended. Research into patient as well as provider perspectives towards the quality of services provided to give important information towards restructuring services to provide optimal medical quality that answers to the wishes of patient and reduces workload for the overburdened health staff. Develop an effective and efficient system for comprehensive services delivery to rural and remote populations in order to achieve universal access. In addition to introduction of mobile clinics, ARV treatment follow up can be linked to the community based Directly Observed Treatment Short course (DOTS) programmes through use of HBC volunteers in treatment follow up and defaulter tracing in the same way as is foreseen for TB under Global Fund round V. The implementation of an effective system that monitors quality of treatment and care in both the public and private health system should be implemented without further delays. Emerging issues: The HIV/AIDS program may be having a variety of direct and indirect effects upon broader health care systems in Namibia that could be positive or negative. Some hospital staff interviewed for the MTP III evaluation suggested that rapid scale up of HIV/AIDS services at the hospital level may be negatively impacting on the quality of services for other health programmes. 67

68 Sub-component 3.2.6: Provision of HAART Expected outcome: 30,000 PLWHA are receiving highly active anti-retroviral treatment (HAART) in public and private settings Progress and achievements Namibia started offering ART in 2003 and the first seven ART sites were launched between July and October of the same year. Currently there are 44 health facilities offering ART i.e. all 34 district hospitals and an additional 10 sub-district facilities (large health centres and clinics). As at March 2007, over 41,000 people had ever been started on ART, of which 33,591 were registered as still being on treatment. 66 percent of patients on ART are women and 16 percent are children. The national target of reaching 30,000 people on ART by 2008, as originally set by MTP III, has already been exceeded. Of note is that in 2005 the UNAIDS and MOHSS revised the national target to 79,942 (2007/08) 92,466 (2008/09) 29. Quality of HAART services overall is high. ART guidelines were recently revised to accommodate new evidencebased WHO standards on HIV/AIDS management and will be distributed and printed soon. Fig 3.1: Number of patients on HAART ( ) Jun 2003 Sep 2003 Dec 2004 Mar 2004 Jun 2004 Sep 2004 Dec 2005 Mar 2005 Jun 2005 Sep 2005 Dec 2006 Mar 2006 Jun 2006 Sep 2006 Dec 2007 Mar Source: Review Team 2007 Reported outcomes for patients on ART in Namibia indicate that 72 percent of PLWHA is still alive since starting ART, 5 percent has died, 2 percent has defaulted and outcomes are unknown in 21 percent of cases. Katutura and Oshakati are the two centres that have the highest rate of patients in the category unknown. It is likely that back migration of Angolans in Oshakati and temporary laborers in Windhoek contributed to a large number of drop outs. Some of these might have reregistered in their home area. The new registration system where patients receive a unique number for life should make follow up of such cases easier. Still, real drop out or defaulting cannot be ruled out especially in the light of a recent adherence study by IBIS in which an important number of patients indicated having difficulties in adhering to treatment mainly due to lack of food. Prevalence of drug resistance is not known. During the last ANC sentinel surveillance, samples were taken for HIV Drug Resistance Threshold. The results are expected shortly. To date it is estimated that two to three percent of the patients receive a second line regimen. There is no information on whether switching 29 UNAIDS, 2006 Report on the Global AIDS Epidemic 68

69 regimens is due to treatment failure or side effects. Some patients are being started on second line treatment to prevent second line medicines from expiring. Fig 3.2: Projected need for HAART Projected need for HAART treatment in Namibia People in need of HAART 2004/ / / / / / / / /13 Source: Review Team 2007 Key issues and challenges: The pace of service rollout and the number of patients seeking care continues to exceed the capacity to establish the necessary infrastructure in a timely manner. Decentralization of follow up of stable ART patients has been slow, resulting in overcrowding at initiating facilities and prolonged waiting time for new patients. Follow up and tracing of defaulters on ART is currently weak making it difficult to assess what has happened to some patients. Patient outcome figures e.g. adherence, defaulters and survival rates are not accurate as data management is a challenge. Some outcome definitions e.g. defaulter are not clear resulting in misclassification of patients e.g. in Ohangwena region patients who missed their appointments by several days were reported as having defaulted. There is limited information available on persons in pre-art care, as some sites continue to report only those who have been started on ART. The current design of the health information system emphasizes ART over general HIV follow up. The overall lack of staff at all levels continues to be a main challenge for treatment programmes i.e. national management level for technical support, coordination, and monitoring; the regional and district level for decentralized training, support and coordination; the health facility level for service provision and community outreach. Recommendations: Expedite the process of decentralizing stable ART so as to bring the service closer to where the patient is and hence contribute to adherence Put in place effective and practical follow up mechanisms for patients on ART and take advantage of the potential of communities in adherence support and tracing of defaulters. Retrospectively do a detailed cohort analysis on patient outcomes for a number of cohorts started in the past year. while the new recording and reporting system will allow more advanced monitoring of patient outcomes over time. These will provide guidance for evidence based decisions on further roll out of the programme to the rural areas. 69

70 Sub-component 3.2.7: Home Based Care Expected outcome: Quality home based care services, including community based care and psychosocial support are available in all 96 constituencies. Progress and achievements An effective system of home based care has the potential to alleviate the burden on health services through prevention, management of minor illnesses and follow up of treatment for chronic illnesses. Over the years an impressive number of volunteers has been trained in Namibia providing services to PLWHA and chronically ill patients. A survey in , reported a total of 4728 active volunteers. A quarter of these are home based care volunteers. Other volunteers are involved in IEC, follow up of OVCs, PLWHA support groups and non health related fields. 80 percent of the volunteers are women and the average age was 27 years against an average 40 years of age amongst their clients. This poses special challenges on the volunteers and their supervisors with regards to counselling and health education skills on taboo subjects such as sexuality 31. Many of the HBC givers are PLWHA. This has dual advantages; as peers PLWHA have a better understanding of the needs of their clients, while they themselves benefit through remuneration schemes as well as the intrinsic value of being able to contribute meaningfully to society. MoHSS runs a programme of Community Based Home Care (CBHC) in a number of regions with assistance from UNICEF. Additional input from the Global Fund allows the ministry to expand the training. The tasks of these MoHSS community volunteers include care for PLWHA and chronically ill patients as well as general community based health promotion, mobilization for vaccinations and advice on hygiene and breast feeding amongst others. In addition a great number of NGOs, FBOs and other CSOs support community based care and support programmes in all the different regions of Namibia. Still coverage of HBC is not universal both geographically and in terms of number of PLWHA assisted. The MoHSS projected that out of the estimated 260,000 Namibians infected with HIV around 57,194 would be in need of Home based care. Cumulative figures from the seven biggest HBC providing organizations indicate a coverage varying from 7.3 percent in Karas region to 193 percent in Oshana. There is likely to be an overlap between the organisation s target populations therefore double counting cannot be excluded. The study in Kunene estimated a coverage of around 40 percent. The volunteer assessment study found that on average volunteers work for more than four hours per day and during four days a week. Workload of care givers also varies substantially between individuals depending on the number of times they 500 N$/month is not enough for most of us. We work 4 to 5 hours a day and when we get home our family asks us: where is the food? Why do you work for others and do not take care of us? (home based care worker) see their clients which may differ from once per month to daily. The study in Kunene also found that care givers spend considerable amount of their time on travel, leaving little time available for actual patient care. 30 Report of an assessment of community volunteers and community based health care programmes, by NEDICO for MoHSS Nov A study to determine the quality and level of HBC activities in the Kunene Region. By Jerry Mameja for Medicos del Mundo. March

71 For a long time MoHSS had accepted volunteer activities to be driven mostly by CBOs, but since 2005 the Family health division within the PHC unit in the MoHSS has been tasked to set policies and standards for home based care. The above mentioned country wide volunteer assessment was commissioned in 2006 and was followed by a conference with all major stakeholders 32 with the aim to foster support towards streamlining HBC amongst all players. Since then some meetings were held with the most important organizations. The process is slow though, partially due to understaffing and competing priorities within the PHC unit at MoHSS. A standard Home based care Kit has been developed and so far MoHSS distributed 6000 kits to the regional medical offices for distribution to HBC givers. No decision has been reached yet on the content of the replenishment kits, which has led to volunteers running out of essential items such as gloves and medicines. Only 27 percent of the organisations supporting volunteers state they conduct a form of performance appraisal of their volunteers 4. Supervision is reportedly done by almost all organisations through team meetings and refresher training. Volunteers interviewed in a number of regions expressed a need for a stronger link with the formal health services. Limited research has been done to identify the actual needs of PLWHA and whether these are met by the current programmes. Overall PLWHA that were interviewed expressed great satisfaction and gratitude towards the work of the volunteers. Although the study in Kunene concluded that not all the needs of the clients are met. Key issues and challenges: CBHC programmes are mostly fragmented and show a great variation in content, quality, training and supervision. Quality is not clearly defined and no standard decription of tasks or standardised training exists for HBC volunteers in Namibia. Curricula vary from one or two days to a two week training and topics depend on the agency that provides the training. Monitoring and reporting focuses more on number of volunteers trained and working rather than on quality of care provided and its effect. There seems to be duplication in efforts of training. A relative high turn over of volunteers with an overall yearly attrition rate of 11 percent is reported creating additional need for training. Coordination is recognized as an important issue by most stakeholders, but progress towards aligning the different programmes is slow largely due to lack of capacity. Lack of food (both in quantity and quality) was mentioned and confirmed by this review as the number one unmet need in all regions. Food distribution programs are erratic and unreliable as they are depending mostly on short donations. Secondary care givers often feel an obligation to provide for such needs from their own pocket, if no provisions are made within the program. Motivation and retention has been a major challenge for most organisations. In general volunteers expect to be rewarded for their efforts and the services they render. This can be in kind (shoes, bicycles, t-shirts, washing soap, access to government food and other distribution items) or in cash. The volunteer assessment study of 2006 showed that remuneration varied from provision of basic equipment only to a monetary incentive from N$10 N$1400. A number of organisations consider basic equipment needed to carry out the tasks, such as home based care kits and books or pens, part of the incentives rather than operational costs. 32 National Conference on Volunteers, Windhoek, 5-7 th December

72 Lack of a clear remuneration policy creates competition between volunteer organisations and contributes to a high turn over due to taking on paid jobs or demotivation. The recent discovery of unfavourable clauses in the new labour act, have resulted in the halting of negotiations on the alignment of remunerations. Guidance is needed on how to ensure an exemption for volunteers within the labour act. Additionally, concerns were raised over the lack of legal support in case of allegations of mismanagement of patients or perceived causing death. The relative vacuum within which HBC volunteers work and the few links to other programmes such as OVC care programmes, delays early recognition and referral for additional needs such as support to children before their parent(s) die (school fees, food, uniforms, stationary, clothes and psycho-social support). Similarly the lack of links to the hospital and clinic health staff is likely to affect smooth referral for various elements of the continuum of care. Furthermore the potential of HBC volunteers as treatment supervisors and adherence counsellors for HIV and TB seems not yet fully explored. Community volunteers working within or directly attached to a health service are expected to be supervised by a clinic nurse. High work load of most nurses and lack of supervision guidelines challenge this concept. Supervisors reported to have little to no time to escort HBC workers or counsellors on their visits and therefore not being able to guarantee quality of the work they do. Sustainability of home based care as a purely voluntary activity without appropriate remuneration is questionable especially in a country with a generalized epidemic with prevalence levels as high as percent of the adult population in several regions. The high levels of care needs within most families combined with high poverty and unemployment rates, leave few people that can afford the luxury to avail themselves and commit substantial time for voluntary services without sufficient support. Why can we as medical volunteers not benefit from free medical aid? Many of us are infected ourselves and need regular medical care... And where is the ministry of health when the family members of a patient come and say I killed their mother? It happens more then once that we take care of a patient, and wash her [ ]. And then the patient dies in our hands and the family blames us! Why can you not provide us with legal protection? (HBC volunteer, towards RMO) Recommendations: Enhance effectiveness, quality and coverage through better collaboration between different government sectors and non-government providers with an aim to align policies and strategies, reduce duplication and competition and to create an atmosphere conducive for linking and learning and sharing of resources between the various partners. Improve effectiveness and quality of both home based care and of treatment follow up for TB and HIV by strengthening the linkage of HBC workers with the health care sector and with other programmes such as OVC care to allow smooth referral to various elements of continuum of care. Negotiate an appropriate remuneration package for volunteers including sufficient legal and social protection. This requires resources to be secured and implications regarding the new labour act to be investigated and acted upon. Conduct a training needs assessment and post-training follow up on enhancement of knowledge and skills to provide opportunities to further tailor capacity building efforts and make these more efficient. Replenish kits for the HBC kits, considering interim supplies with most essential items through the regional pharmacies. 72

73 Sub-component 3.2.8: Access and Use of Services This section refers to the sub-component 3.1.2: IEC to support expanded treatment, care and support programs and to sub-component 3.2.8: Access to care for vulnerable populations. Expected outcomes: 50 percent of the general public have a satisfactory level of knowledge on treatment, care and support for HIV/AIDS; and 100 percent of vulnerable populations have access to comprehensive medical, psychosocial, and palliative care. Progress and achievements 33 Knowledge of HIV/AIDS testing and treatment services. MOHSS has been assisted by Johns Hopkins University s Health Communication Partnership (HCP) to develop, test, produce, and disseminate essential communication materials on PMTCT, VCT, ART, treatment and care in Namibia. At the community-level, HCP has developed and implemented community mobilization activities that assist communities in increasing awareness and HIV/AIDS-related interventions such as VCT, PMTCT, ART and support to OVC. To improve quality of health care, HCP has developed a PMTCT patient-provider interpersonal communication curriculum to be used with Mission and government hospital personnel. These activities are being tracked through very well-designed monitoring and evaluation activities. The Social Marketing Association, Lironga Eparu, and the Aids Law Unit of the Legal Assistance Center have also developed and disseminated information materials for the general public, the sexually active population, and PLWHA. Access to HIV testing and treatment services. Since 2004, a tremendous amount of progress has been made by the Ministry of Health and Social Services (MoHSS) and its development partners to improve the physical availability of HIV testing and treatment services. From 2005 to 2006, the number of MoHSS VCT service delivery points increased from 206 to 285, and the government appears to be on track to achieve the goal of offering VCT services in 100 percent of Namibian government health facilities. Rapid testing reduces what can be substantial delays in providing results to clients and is now available in hospitals and a limited number of lower level facilities. The introduction of community counsellors to most health facilities appears to have substantially alleviated human resource capacity constraints, thereby improving VCT access. The Social Marketing Association s New Start Centres, the other key source of VCT services, has also expanded, from 12 centres in 2004 to 19 centres in All centres are reported to offer rapid testing and are located only in urban areas where HAART is available from government hospitals. SMA will soon be closing two New Start centres in southern Namibia. This decision was based on lower than expected numbers of clients rather than on estimated needs. 33 The information presented in this section is limited by the unavailability of data from the 2006 Demographic and Health Survey, which collected information on knowledge of services, attitudes, practices, and selected types of health care utilization from a nationally-representative survey. 73

74 Prevention of Mother to Child Transmission of HIV (PMTCT) has become increasingly available in recent years. The MoHSS reports that 188 health facilities were providing PMTCT, up from 44 facilities in March However, at the clinic level, the range of PMTCT services offered is reported to vary widely. For example, some clinics only provide VCT, but do not provide nevirapine (data on the number of PMTCT facilities by the types and numbers of services provided are currently not available at central MoHSS). Currently, all 34 district hospitals are providing PMTCT services, rapid testing has been rolled out to 70 PMTCT sites since July 2005, and efforts to further scale up the programme are on-going. Nevirapine for PMTCT appear to be in good supply. DNA-PCR to detect HIV in infants born to HIV positive mothers is only available in Katutura Pediatric Clinic, and 58 facilities in the country send specimens to NIP for analysis. This leads to small but acceptable delays in receiving results (up to two weeks). The provision of Highly Active Anti-retroviral Treatment (HAART) has expanded rapidly. Since the program was launched in June 2003, HAART provision has been rolled out to 34 government hospitals and ten non-hospital sites. Use of HIV/AIDS testing and treatment services Since 2004, there has been a substantial increase in the use of VCT, PMTCT, and HAART services. This has been made possible through the increased availability of services along with complementary Information, Education and Communication efforts. The introduction of HAART has fuelled a substantial increase in the use of VCT services. As indicated by Global Fund tracking data, the number of clients receiving VCT services at stand-alone and PMTCT service delivery sites, which presumably includes both MoHSS and New Start programme facilities, was 57,560 by December 2006, far surpassing the government s target of 25,000. Based on estimates from 2006 Progress Report on the MTP III, it is assumed that the New Start programme, which consisted of only 18 facilities at the time, accounted for about half of all VCT encounters. In MoHSS facilities, the majority of clients are women, largely due to the PMTCT programme. Also the New Start facilities report to have overall tested more women than men, but this has recently changed with the majority of clients being men. One possible explanation for this finding is that men may perceive that their confidentiality can be better preserved in New Start rather than the MoHSS facilities. Preliminary results on VCT service utilization from the 2006 Demographic and Health Survey showed 51 percent of women aged years to have ever been tested and knowing the results compared to 32 percent in men. A 2007 USAID-supported study carried out in four Namibia communities (Rundu, Walvis Bay, Oshakati, and Keetmanshoop, all within 10 kilometres of hospital treatment centres), by NawaLife Trust and Johns Hopkins University finds that study respondents are three times more likely to have received HIV tests then they were two years ago. The study found that more than half of respondents 15 years of age and older had ever been tested for HIV, and between 31 percent and 45 percent had been tested in the past year. Among TB clients, routine testing increased from ten percent in 2004 to 44 percent in the first quarter of During visits to the regions by the MTP III review team, hospital staffs in all regions of Namibia indicate that the percentage of TB clients being tested might be even higher. 74

75 Routine testing for PMTCT has increased steadily among pregnant women, from 5,500 in fiscal year 2004/05 to 13,629 in fiscal year 2005/06. According to the 2006 DHS, the percentage of pregnant women who utilize antenatal care services by a trained provider is high in Namibia (96 percent), and according to the HIS statistics for the year 2006/ percent of these visits were in clinics that provide PMTCT services, with a big variation between regions (varying from below 40 percent up to 100 percent). Overall coverage is estimated between 40 percent and 62 percent. The uptake of nevirapine in babies that are born in hospitals is over 90 percent. Since the introduction of HAART provision in 2003, the national target of reaching 30,000 people with ART by 2008, People who abuse alcohol cannot start on originally set by MTP III, has treatment. [ ] they forget to drink their tablets and already been reached. As of it interferes with the effectiveness of the treatment. 2006, MoHSS estimates that the We therefore tell them they have to stop using alcohol first. [ ] any alcohol (nurse in Kunene number of individuals receiving region) HAART increased from 1,164 in March 2004 to 33,591 in March As of 2006, there are estimates that 2,111 patients were waiting to start treatment. HAART is also provided by private hospitals (both for-profit and non-governmental organisations) but these facilities are located predominantly in Windhoek and a few coastal areas. Both medical and social criteria are used to decide on eligibility for treatment. Social criteria include: to not abuse alcohol or other If they live far away it is substances, to have a fixed home address over the better for them not to start past three months, to be able to visit the clinic for treatment because they will regular follow up and to have a treatment supporter not be able to pay for identified. These criteria that are intended to transport each time and cannot continue (nurse in a assess risk for defaulting and treatment hospital CDC) discontinuation seem to be used more strictly than needed in a number of clinics. Key issues and challenges Namibia faces a number of challenges to further scaling-up accessibility and utilization of HIV/AIDS services: More effective programme monitoring and applied research is needed on the individual-, household-, and community-level determinants of access to services and health care seeking behaviour in order to inform the design and implementation of testing, and treatment interventions. Social eligibility criteria are used too strictly and form an unnecessary barrier for a number of patients in need of HAART. Furthermore, insufficient referral between public sector and community support systems and a lack of treatment adherence education are significant gaps that impede treatment. Human resource constraints remain a key barrier to further scaling-up and sustaining HIV/AIDS services. Shortages of doctors, nurses and pharmacists in hospitals and other facilities are preventing the government from moving forward with plans to provide both facility-based (i.e. rapid testing, HAART) and outreach services to rural areas. Lack of space in outpatient settings limits the ability of MoHSS to accommodate HIV/AIDS patients and to ensure confidentiality. Stigma and discrimination against PLWHA continues to limit the numbers of individuals who seek out VCT services, the gateway to receiving treatment, care and support services. The issue of stigma remains a particularly important barrier among men. While information is not available on the numbers of individuals from vulnerable populations receiving VCT services, interviews with a wide variety of 75

76 stakeholders at both the national and regional levels indicates that uptake among groups such as migrant workers, vulnerable children, sex workers, and gay individuals is low due to a number or reasons, including stigma, fear of discriminatory treatment in health care facilities, and inability to receive permission from employers to take time off to receive testing. There appear to be stark disparities between urban and rural communities in the physical availability and use of HIV/AIDS related services. Long travel distances and waiting times, and high transportation costs are important barriers to service use among individuals in rural areas, particularly for ART services that require clients to be accompanied by a care supporter. The practice of charging user fees to clients of HIV/AIDS-related services varies widely. While VCT and HAART services are reported to be typically free of charge, both poor and non-poor PLWHA are often charged fees for accessing services. Interviews with members of PLWHA support groups suggest that the practice can be a barrier to the utilization. The government user fee policy and guidelines that protect the poor and other vulnerable groups from user fees is interpreted and implemented in different ways by registration clerks at clinic entry. In one region, Hardap, access to VCT services is expected to decrease rather than increase, as the SMA recently announced that the New Start Centres in Keetsmanshoop and Rehobeth will close in July 2007 due to lower than expected utilization by the program s principle donor, leaving the hospital as the only source of VCT services in these cities. The use of traditional medicine remains high in Namibia (i.e. African potato, Nama medicasie, etc.). This often leads to individuals delaying or forgoing treatment from trained health care professionals. Interviews with ART doctors in district hospitals suggest that default rates are significant due to the lack of food, poverty, and alcohol and drug abuse. This is corroborated by the first results of a treatment survey amongst PLWHA, that found relative a high percentage of people having difficulties with adherence and around 20 percent having stopped treatment because of side effects and lack of food to take with the drugs. Information on the numbers and percentage of clients who have defaulted was not readily available within the services. Limited information is available in Namibia on the supply of services and on the need and demand for services (both public and private). This makes it difficult for policymakers and managers to make evidenced-based decisions regarding the scale-up of HIV/AIDS services and the proper role of the private sector. Recommendations: Increase emphasis on coordinated multisectoral efforts to reduce the barriers of stigma and discrimination against PLWHA and to find ways to overcome other social and economic barriers in accessing treatment. Provide additional welfare assistance (including food security assistance) and alcohol and drug abuse counselling to HAART clients in order to improve on adherence. Multisectoral involvement is urgently needed. Re-enforce the user fee policy and exemption rules to ensure the poor have access to HIV/AIDS testing and treatment services. Further increase Monitoring and Evaluation capacity. This is essential in order to ensure that information is available to assess the effectiveness of specific programmes on access and use of HIV/AIDS. Increase emphasis on human capacity development and preparing physical infrastructure to scale-up VCT, HAART, and other HIV/AIDS services, particularly in rural areas, and ensure the sustainability of services once programmes such as PEPFAR and The Global Fund end. 76

77 COMPONENT 4: IMPACT MITIGATION SERVICES The impact mitigation service component in MTP III aims at strengthening and expanding capacity of local responses to mitigate socio-economic impacts of HIV/AIDS. This component covers four key areas of responses, namely: Capacity development for local and community responses. Capacity development of local PLWHA support groups and their families. Services for orphans and vulnerable children. Addressing poverty, food security, nutrition, and housing. In addition, MTP III recognises that local responses are a combination of building the knowledge and skills of key actors in the community; facilitating support from different sectors, especially local authorities, education, health and agriculture; and building capacity of service providers such as local NGOs. Effective management and coordination at this level is crucial for success. Good progress has been made in establishing RACOCs and CACOCs in all regions. All RACOCs were trained and have developed plans and receive a budget for coordinating the response in their region. Regions are visited regularly by multidisciplinary teams to assess progress and advise RACOCs on improving coordination and response. A number of excellent initiatives have been developed by community based organisations such as NGOs and FBOs to provide services to people affected by HIV/AIDS and/or to strengthen the local response. The systems for direct support to OVCs and PLWHA and affected families are in place and an increased number of OVC and PLWHA are benefiting from grants, food and other support schemes. PLWHA support groups are increasing in number and are now found in all regions. Umbrella organisations for PLWHA (Lironga Eparu) and for CBOs (NANASO) have been strengthened in their organisational structure. Other umbrella organisations such as NABCOA have actively supported and coordinated private response. Key issues and challenges: There is a lack of national level focus on strategically planned, long term impact mitigation. A mix of prevention and care service activities and indicators at a local level are enlisted to strengthen local responses to mitigate socio-economic impacts of HIV/AIDS. Despite the numerous well designed individual local responses, the overall response is fragmented and often unsustainable, being largely dependent on single donor funding. The systems to assess actual needs and the monitoring of the response towards OVCs, PLWHA and affected households are weak, constraining a targeted response and assessment of effective coverage. Furthermore RACOCs and CACOCs are insufficiently equipped and mandated to effectively coordinate the response to assure a full coverage of all regions with all required elements. Services sometimes fail to reach OVCs and PLWHA in need, despite laws and systems to help ensure this. This can be attributed to lack of awareness around entitlements, complex benefit application systems, understaffing of social welfare offices at all levels, and insufficient allocation of funds. CBOs vary greatly in their approaches and lessons should be shared, in particular examples of participative approaches for communities. Meaningful involvement of PLWHA in assessment, programme planning, implementation and monitoring and evaluation is still scarce and should be promoted further. 77

78 Sub-component 4.1.1: Developing Capacity of Local Responses Expected outcome: 80 percent of targeted communities have a local response to HIV/AIDS. The main aim of this component is to establish, strengthen, and support communities to take action to respond to HIV, STIs and TB. This aim is broader than its current restriction to impact mitigation within the MTP III document, considering the fact that effective local responses to achieve this aim will cover prevention to care continuum including impact mitigation. Hence, consultations were made with key stakeholders at national level, in the regions and the constituencies with full consideration to the five key components/intervention areas as stated below: Enabling Environment Prevention Treatment, Care and Support Impact Mitigation Management and Coordination Using this approach enabled the review of local and community responses beyond impact mitigation and resulted in key recommendations on strengthening regional, local community responses to the epidemic. Progress and achievements At the community level a number of actors have shown increased involvement in the fight against HIV/AIDS. These include official, traditional, and Christian faith based leaders who helped develop AIDS awareness and prevention messages, contributing to stigma reduction and creation of enabling environment. A substantial number of local and international NGOs are supporting the local response with various activities and levels of success. The establishment of structures such as RACOCs and CACOCs for coordination of activities in the regions and constituencies is a good initiative. To date, all 13 RACOCs are in place, though their functionality varies. Presence of an INGO providing technical assistance and financial support seems to have a positive effect on planning capacity and functioning of RACOCs, as was observed in Erongo and Kunene regions. The March 2007 progress report states that 120 CACOCs have been established, 80 (66 percent) have received training and 79 (57 percent) had plans and budget to fund and implement their activities 34. Half of the CACOCs had a volunteer coordinator installed. Core functions and activities of CACOCs have been identified based on MTP III terms of reference. Although RACs reported that 76 percent of the CACOCs are active, this could not be substantiated considering the above analysis and loose interpretation of active by the RACs. The mission was unable to visit any of the CACOCs to ascertain their functionality and performance. Only constituencies with presence of International NGOs, FBOs and some NGOs such as Red Cross, DAPP, Catholic AIDS Action, AIDS Care Trust, Nawalife, etc. have active interventions going on in the areas of prevention, VCT, HBC, OVC. In addition, the presence of these organisations, especially the INGOs, has enhanced coordination amongst RACOCs and CACOCs. 34 Draft Progress report on the 3 rd Medium Term Plan on HIV/AIDS. 78

79 Successful community level intervention models can be identified and used as examples for wider coverage and reach. For example, the Walvis Bay Multipurpose Centre programme is promoting active involvement of PLWHA, and men and women who have been tested for HIV, as motivational speakers and peer educators in the promotion of testing and reducing of the stigma attached. Effectiveness and efficiency of services delivery follows the concept of local response development and builds on strong co-ordination and integration of a variety of services by different actors within the same premises (see figure below). BUILDING RELATIONSHIPS IN OUR COMMUNITY The Municipality of Walvis Bay Catholic AIDS Action, W/Bay Swakopmund VCT COLS & True Love Waits Committees RACOC/DAC etc. SMA Corridors of Hope Project W/Bay MOHSS ARV & TB CLINICS Fisheries & Other Industries Community Leaders & Churches Source: Walvis Bay multipurpose centre Another innovative approach uses the arts as a medium of reaching young people with Sexual Reproductive Health and HIV/AIDS messages as implemented by the Ombetja Yehinga Organisation (OYO) Youth Education Programme in Erongo, Kunene and Khomas regions. Yelula, PIN, CLAAHA and Nawalife are strengthening their local and community responses by addressing factors that fuel the epidemic such as alcohol, certain traditional practices, gender inequality, economic disempowerment, stigma and discrimination. A more recent initiative is the UNDP supported Community Capacity Enhancement (CCE) Programme. It emphasises combining responses to HIV/AIDS at community and local level with other developmental issues. Key issues and challenges: Only three out of the eleven activities enlisted on local responses in the MTP III are currently partly implemented, but there is no data available to ascertain the status of implementation. These activities include establishment of constituencies and village committees, training of community counsellors and provision of technical assistance and financing to local NGOs for OVC interventions. A key concern is that the concept of local response development is not well developed and understood by the many actors working at community level. This leads to many localised initiatives not necessarily addressing the full continuum of services and moreover not well coordinated and facilitated. The many interventions at community level such as implemented by CSOs are not well captured in the indicators in MTP III. This is reflected in the CSO reporting format and monitoring and evaluation plan that only has indicators for OVC interventions. Progress reports up till March 2007 only document RACOC and CACOC actions despite other interventions at community level. This hampers ascertaining the status of MTP III implementation at sub-national and community level. Issues on local response yet to be covered or inadequately reported include: 79

80 o o o o o o o o Policy for remunerating, recognising and assisting community volunteers. Few participatory vulnerability and risk assessments and community action planning have been developed (exceptions are community based programs such as Nawalife, CLAAHA and Yelula). Community based committees have been trained on HIV/AIDS but it is unclear if content covers development of local responses and programme management. None of the communities have been trained on nutrition surveillance. Absence of funding hampers initiation of projects by local authorities, despite development of the guide Steps to Local Authorities HIV/AIDS Response. Despite ongoing interventions in the schools, there is no data on the percentage of schools with functioning HIV/AIDS Committees. Similarly there is no data on carers and foster parents registered and trained. A number of faith based interventions cover prevention and care on HIV/AIDS, but to what extent HIV and AIDS has been mainstreamed into church activities could not be ascertained. Information on effectiveness of communities responses in most regions is limited. Only few studies exist such as the KAPB study conducted by Medicos Del Mundo (MDM) in Kunene and Erongo regions. Unfortunately these reports are not widely available hence not used to inform community responses or to expand existing initiatives to address the issues raised by these studies. Despite good progress, the role of NANASO to support linking and learning between CSOs can still be improved further. Good models of community response do not necessarily cover all aspects of prevention to care continuum, including impact mitigation except in very few places. This results in lack of comprehensive interventions in the constituencies and the regions to tackle the epidemic effectively. This is also coupled with the challenge of wide distance between constituencies and regions which prevents beneficiaries from accessing available services irrespective of the location. Despite the fact that local authority, education, health and agriculture sectors were specifically stated in MTP III to guide and facilitate support for impact mitigation, there are no clear plans and guidance from these ministries on impact mitigation. Most of the plans are still limited to prevention interventions and not on mitigating impacts of HIV/ AIDS. Knowledge of some constituencies and stakeholders on MTP III is insufficient for them to identify with their obligations. Also it was confirmed there was no mechanism to collate their inputs using the bottom-up approach while developing the MTP III. This is more specific to the Local Authorities. Resources to NGOs and CBOs are inadequate to reach beneficiaries at the community level. This limits the scope of interventions especially in hard-to-reach areas. Available funds are often temporary in nature, challenging the continuity and sustainability of some good projects e.g. Community Led Action Against HIV/AIDS (CLAAHA) STEAR project,a sound initiative mainstreamed to agriculture (farming with HIV/AIDS). The involvement of lowest level of government is still minimal. The ALAN has developed Steps of Local Authorities HIV/AIDS Response, which covers key areas of MTP III. But there are challenges with implementation as ALAN is seen as and independent body, hence not receiving funds from the government despite their strong technical arm AMICAALL that is versatile in HIV programme implementation. 80

81 Recommendations: Strengthen CACOCs to better understand their role in stimulating local responses e.g. understanding principles of community mapping and action planning, coupled with identification of one NGO in each constituency who is tasked with the role of facilitating local response development. CACOCs should have tools for planning, management, coordination, monitoring and budgeting. Impact mitigation responses need to go beyond prevention to care, to include adequate planning to ease and lessen the negative impacts of HIV and AIDS. For example, putting plans in place for replacement of teachers lost to AIDS. Recruit full-time Coordinators for CACOCs to ensure effectiveness and efficiency in coordinating HIV and AIDS activities at constituency level. In addition, vacant positions in the secretariats of RACOCs should be filled for efficiency reasons. This will allow time to reach all stakeholders implementing programmes in their constituencies and regions irrespective of the sources of funding and capture the interventions. Evaluate exisiting models in communities for effectiveness and efforts should be put in place for expansion of best practices. This should include technical and financial support as required for the expansion of the successful initiatives/models. DSP and NANASO have an important role to play in facilitating sharing of lessons learned. Develop comprehensive interventions and indicators on local and community responses for MTP IV to guide specific activities and output indicators at that level. A full mapping of available resources (funding, transport etc.) and identifying gaps is much needed. This is to inform allocation of resources and identify needs and opportunities for NGOs and constituencies to expand activities/interventions; and to ease implementation considering the vast distance between and amongst regions. Discuss human resource capacity gaps with VSO and other development partners for possible assistance through recruitment of volunteers to occupy the positions while government continues to work on building human resources for future sustainability. In addition, identification of gaps will further guide deployment of new partners (INGOs) as well as the national NGOs to broaden interventions and coverage. Put plans in place to reduce single donor dependency and to raise continued financing of successful initiatives e.g. the CLAAHA STEAR project. Consider allotment of resources and active involvement of local authorities in response to HIV and AIDS. Make extra efforts to ensure that low prevalence in remote and çlosed regions such as Kunene is maintained when economic development grows and new infrastructure opens the region. HIV interventions should be mainstreamed effectively into development projects such as road construction, building construction..employ a more participatory approach at constituency level to raise awareness on the needs and the challenges related to the HIV/AIDS epidemic. This will guide the development of plans, focus and targets for community actions for prevention, care and impact mitigation. A community based monitoring system needs to be part of the plan. This will also serve as a good data base to assess the contributions the communities are making in the five component areas of MTP III. 81

82 Sub-component 4.1.2: Involvement and capacity building of PLWHA Expected outcome: Increased number of well functioning support groups for PLWHA and their families. This review has looked at involvement of people living with HIV and AIDS across the five components of interventions with focus on relevance, access and availability, level of inclusion and sustainability of HIV/AIDS related interventions and programs. Progress and achievements Legal and counseling support is available through LAC-ALU and through Lironga Eparu to its members and civil society. Lironga Eparu has appointed focal persons in a number of constituencies who are expected to support local PWLHA peer-support groups. These groups provide services to PLWHA on peer counseling, treatment support, psychological support, skills training to PLWHA, OVCs bereavement counseling, and succession planning. PLWHA support groups advocate for equal access to services and try to support in cases of people being refused certain services. Over the past years Lironga Eparu reached almost 6000 PLHA. A reasonable number of PLWHA has come out and shared their HIV status which could be seen as an indicator of reduced stigma and will by itself further reduce stigma. Key issues and challenges: GIPA is still undefined and lacks policy and legal backing and support; poor understanding and interpretation of GIPA principles by key stakeholders including some PLWHA networks; and problems in promoting GIPA as an effective instrument in the broader HIV/AIDS response. PLWHA Network/support groups and associations employ varied definitions of GIPA, but all agree that GIPA should lead toward a meaningful and full involvement of PLWHA in the national response at all levels. The public and private sector implementing HIV/AIDS programmes have very little understanding of the principle of GIPA and even where they engage with PLWHA, they do not do so with the GIPA concept in mind. Respondents from the NGOs working in HIV/AIDS have a better understanding of GIPA and indicated that PLWHA voices should be heard and integrated in all policy and decision-making fora. Lironga Eparu appears unable to fully embrace its critical role in representing the PLWHA community, despite making considerable progress in improving its organizational structure. There are PLWHA support groups who decline to be part of Lironga Eparu, and still others who are oblivious to its existence, for example Etunda in the North. Issues around stigma continue to hamper efforts to scale up prevention and treatment, despite some anecdotal evidence indicating people are less fearful of visiting and being seen at CDC clinics in the country. Still little is known about how stigma affects PLWHA and their families, how it influences prevention and care efforts, and which measures might best reduce stigma and discrimination among different population groups. Several issues were raised affecting access and use of various services. These include waiting lists, waiting time, travel distance and cost, user fees, 82

83 implementation of social eligibility criteria, and inaccessibility of food. Also, complaints were voiced by several PLWHA on a negative attitude of staff members in some service delivery points, which may be attributed to burnout and fatigue. Access and use of services is described in more detail under component Most support groups face a lack of funding and technical input for their activities in addressing human rights and stigma, designed under MTP III. Due to a general lack of resources the foreseen cadre of paralegal workers are not in place to render advice on human rights issues for PLWHA and their families. The fact that only 6000 PLWHA (out of around 230,000 ) are reached through the Lironga Eparu network, shows the urgency in strengthening PLWHA organisations in reaching their constituents. Rights of PLWHA are not always fully adhered to, for instance HIV testing is often offered as a routine test rather than through VCT and confidentiality is not in all cases guaranteed. The official bodies in place to oversee law enforcement and investigate cases of discrimination, such as office of the Ombudsman and LAC-ALU, have limited capacity to take up these roles. Recommendations: A better description of the potential role of support groups for PLWHA regarding self help, involvement in prevention and treatment support needs to be described and translated in action plans. NGO s and FBO s should be encouraged to invest in strengthening of patients support groups and groups of PLWHA and provide tham with the necessary resources and capacity development. There is critical need to strengthen community driven activities with close involvement of PLWHA groups, through provision of resources (technical assistance funds). These services need to reach the geographically hard to reach communities. To ensure access and equity, programs need to be tailored to meet the particular needs of PLWHA and affected communities, depending on the context. Gender inequities that impede access to services and programs for women or men, including those living with HIV/AIDS, need to be understood and addressed and the involvement of men into HIV/AIDS response should be stimulated. 83

84 Sub-component 4.2: Comprehensive services for OVC, Caretakers and PLWHA Expected outcome: Guaranteed access to comprehensive services for 85 percent of OVC, their caregivers, especially older people, and PLWHA in all 13 regions Progress and achievements Within the Ministry of Gender Equity and Child Welfare (MGECW) the division of child welfare was established and social workers were appointed in all regions. The OVC policy has been adopted and published in February 2005 and a national plan of action (NPA) was drafted and finalised in 2006, which includes a monitoring and evaluation plan. The NPA includes a five year strategic plan on rights and protection, education, health and nutrition, care and support services and mobilisation, integration and networking. The OVC permanent task force established by a cabinet directive in 2002 oversees this NPA. Implementation has been delayed though. To date nine out of thirteen regions (69 percent) have established Regional OVC Forums and 25 of 107 constituencies (33 percent) in 13 regions have established constituency OVC Forums. Brochures on grants were developed and translated into a number of languages to raise awareness on entitlements and ways to obtain grants. Grants can consist of four different forms: i) maintenance grants; ii) special maintenance for children with disability; iii) foster care grants and: iv) place of safety allowances. Progress was made in terms of grant support and by the time of this review a total of around 58,000 OVCs or caretakers received grants 35. Additionally as of February 2007, 18,920 disability grants were issued to adults of which 8.6 percent is estimated to be HIV related, which is 1627 grants 36. Mar 2006 Feb 2007 Total # children accessing welfare grants 40,685 58,000 Maintenance Grant 31,685 46,740 Foster Care Grant 9,000 11,260 Children home subsidies 1,800 2,000 Estimated Place of Safety allowance In order to improve the management and monitoring of grants and support, an OVC database has been developed, but is yet to be implemented. Additionally with the assistance of a team of Namibian-based consultants who were commissioned by WFP and MGECW in 2006, recommendations have been developed to streamline individuals access to documents such as birth and death certificates. Key issues and challenges: The MTP III provides direction to regions on general needs for OVC, but lacks the how to (e.g. strategy development, financing) for implementation. The number of orphans and the issues facing them, can vary from region to region, and the MTP III does not take this into account. Monitoring the coverage and effectiveness of the response to OVC is currently very difficult as there is no good data available on the number of OVCs that are in need and qualify for support. There is no consensus on the overall number of 35 Source: Ministry of Gender Equality and Child Welfare 36 Source: Ministry of Labour 84

85 orphans or numbers at the regional level. The OVC Database has been developed, but is not yet fully functional and the challenge remaining is to find ways to assist regions in gaining access to internet. Implementation of OVC activities in the MTP III are constrained by a lack of coordination, lack of human capacity and financing and by unnecessary complex procedures. Responses to OVC are hampered by a lack of coordination between and within ministries at both the national and regional level and by a lack of national support. This leads to inconsistent and fragmented activities driven by the MGECW, donors and various NGOs. The role of the RACOCs and CACOCs is important for the development and implementation of regionally specific programs. A key finding is that none of the RACOCs or CACOCs interviewed had developed an OVC work plan or formulated targets based on the region s prevalence rate, both of which together would provide a comprehensive picture of the region s needs. Government funding to RACOCs is merely proportionate, and does not take into consideration the burden of disease nor number of known orphans in the region. Regional OVC Forums, which in theory should be functioning in all of the regions, appear to function only in a limited number. In some cases, members of the OVC Forum were not aware of the Permanent OVC Task Force at the national level, yet this linkage is critical in ensuring consistency of action at every level. The limited number of social workers in the region (one per region) does not meet the demand for the number of responsibilities they shoulder. Moreover the appointments of positions relating to HIV/AIDS in the regions have not always been based on technical expertise, but rather political motivations. Adequate representation of MGECW at the regional level is crucial in operationalizing current and pending OVC plans. Accessibility of grants: People interviewed raised concerns that grant funds for children do not consistently support the needs of all OV s. The system is in place, but for a variety of reasons the money appears not to reach the children in some instances. The children most in need are not always able to access services due to isolation in the rural areas, stigma and discrimination, and poor coordination among implementing organizations. The culture of non-disclosure of one s HIV status further hinders the process of operationalising the OVC policy and creates a barrier to individuals accessing services. In order to qualify for grants, OVCs require access to documentation such as birth certificates and death certificates. This is challenging for OVCs and their caretakers. The DHS 2002 revealed that 71 percent of births are registered. Main reasons for non registration are travel distance and not knowing where and how to register. This was noted especially in border communities, and in families of mixed nationalities. It appears that in many cases OVCs are not being exempted from school fees. The process of filing for exemption is lengthy (six months one year) leading to children missing school terms. Furthermore the documentation is often incomplete and schools are sometimes reluctant to exempt children because of the loss of income to the school that will ensue. Some schools may be unaware that they can be reimbursed for exemptions, and also unaware of the process by which to submit applications. MGECW is a relatively poorly funded agency, especially in relation to the number of responsibilities it has. For instance, the public service commission (PSC) has approved a substantial increase in the number of social workers, but funding has still to be approved. Coordination within MGECW at both national and regional 85

86 levels appears to be weak. For instance, different directorates in the Ministry appear not to coordinate their work in relation to children and young people. Recommendations: Strengthen the needs assessment, planning and monitoring of the response to OVCs. MOHSS, MoLSW and MGECW should collectively support effective assessments to take place in each region regarding the number of OVCs and their needs, and to develop needs based planning and budgeting. Ensure that financing and budget allocation to the different regions follow the needs as identified rather than a nominal regional contribution. In addition a consistent monitoring should be set up to measure effectiveness and coverage of the response that is given in each region. Ensure better coordination of OVC response by the various ministries involved and team building for OVC focal points in these ministries. At national level, this might include joint missions to other countries to look at OVC planning and service delivery, which might provide further direction for ministries working together and sharing information. Make policies and relevant information available to all staff and parties responsible for support to OVCs in the regions. It would be helpful to support the translation of the MTP III and other current and pending policies/plans for OVC into local languages. Simplify, shorten and make more user-friendly the processes of accessing grants and other benefits for OVCs such as exemption from school fees. This requires the MoE, MoGECW and MoLSW to review the number of steps involved at the ministries at the national and regional level and to streamline processes, and most importantly provide directives to the regions on how to implement the process. Supervision is needed on the implementation of the policies. Share with MOH and MOHA and adopt as soon as possible the recommendations regarding reducing the burden of OVCs and caretakers in accessing legal documents formulated by WFP and MGECW in their report, A Review and Plan to Ensure the Systematic Transition of OVC from Food Assistance to Government Grant (2006). Stimulate the training of social workers and retention in order to increase the number of social workers (e.g. by instating a bursary-plus-bond system to fund students and to improve retention). In order to reduce the workload of individual social workers and to provide more effective support to individual OVCs and care takers MOH/MOE/MGECW/MoLSW should consider supporting the development of yearly budgets for social workers, allowing them to hire community activators who can provide a range of support. Strengthen the MGECW and review its budget for child welfare so that it is commensurate with the Ministry s responsibilities in this area; adequate resources also must be available so that the grants can be disbursed. Linking mechanisms should be strengthened to improve internal co-ordination. There is also a need to strengthen the Ministry s links with the MTP central structure. 86

87 Number of OVCs Reached Republic of Namibia: Mid Term Review of the Third Medium Term Plan on HIV/AIDS, 2007 Sub-component 4.3: Poverty, Food Security, Nutrition and Housing Expected outcome: 85 percent of HIV/AIDS affected families in need receive support to address the depressed socio-economic conditions including support for income, food security, nutrition and housing of Orphans and Vulnerable Children (OVC) and People Living with HIV/AIDS (PLWHA). The MTP III enlists various activities to achieve the above outcome. For each activity a specific project outcome is suggested together with implementing partners. Progress and achievements: The MGECW is in the process of developing a comprehensive OVC database with assistance from USAID-PACT. The Ministry has also released one social worker position at the National level in order to recruit a Monitoring and Evaluation officer whose responsibility will be to establish and maintain the database. 37 Orphans are identified and registered by MGECW with the assistance of NGOs for various services. By March 2006, a volunteer Record Clerk was recruited for each constituency to be responsible for completing OVC application forms and to quicken the process of transferring OVC onto the government grant. 38 World Food Programme (WFP) is the major source of food supplements such as fortified maize meal, oil and Corned Soy Blend (CSB). These supplements provide temporary relief to food insecure OVC, pending their inclusion onto the government grant system. WFP is operating in five regions namely; Caprivi, Omusati, Ohangwena, Oshikoto and Kavango. It operates through the Namibia Red Cross Society (NRCS), the African Humanitarian Action (AHA), the Evangelical Lutheran Church in Namibia (ELCIN) and the Catholic Aids Action (CAA). Fig.4.1 indicates the number of OVC reached by WFP for the period (May). From the figure below, there has been an increase of OVC reached since Fig ,000 70,000 60,000 50,000 40,000 30,000 20,000 10, WFP Food Supplement Support Years Source: WFP distribution update, MGECW/WFP OVC support programme. A Review and plan to ensure the systematic transition of OVC from food assistance to Government Grants, Final Report, Namibia MGECW/WFP OVC support programme. A Review and plan to ensure the systematic transition of OVC from food assistance to Government Grants, Final Report, Namibia

88 NRCS provided food parcels to PLWHA on ART for six months in 2005/6 season in addition to counselling, care, prevention, financial and material services through its eight regional branches. Vergenoeg DAC in Omaheke is currently feeding 245 school going children and 50 vulnerable children. The Khomas region RACOC procured N$ 600,000 worth of food stuff for 2007 for the AIDS Care Trust (ACT) to distribute food to vulnerable PLWHA. On a monthly basis, Namb Mill donates 250 kg of maize meal to cater for 300 beneficiaries under ACT. In addition, ACT also procures instant porridge from its own resources. The common feeding programme is the wet feeding which is commonly known as soup kitchen. All organisations involved in feeding have a soup kitchen and each one prescribes the food items and rations depending on the availability of food. The commonly used take home ration is known as e-pap. NANASO has attempted to develop guidelines for feeding different categories of people. There has been realisation that the problem of food insecurity is becoming real in the management of HIV/AIDS. To this effect, the Ministry of Health and Social Services (MoHSS) has submitted a discussion paper on Food Support and supplementation for people living with debilitating illnesses to government for consideration as a response to managing HIV and AIDS. 39 All 13 regions have communities that have planned for vegetable gardening, agriculture and income generating activities, though access to land and water is a challenge for most of the communities in Kavango, Erongo, Khomas and Omaheke regions. Other Income generating activities that people are engaged in include knitting, bead and leather works, and other crafts skills to enable them to meet their daily needs. In addition, most programmes have a feeding component for the clients/patients. In 2005/06 season, NRCS provided seed and fertiliser to 2,000 households in Caprivi and Ohangwena regions and also established vegetable gardens in the seven target regions. Realising the growing problem of food insecurity, NRCS has recently developed a food security strategic plan. A loan system has been introduced by the NRCS to support three associations in the Caprivi region amounting to N$ 30,000 for fish farming and vegetable/crop farming, which is also accompanied by business training. So far 35 association members have been trained. MoAWF and MGECW, in partnership with FAO and WFP, are piloting a microproject; the Junior Farmer Field and Life Schools (JFFLS) in three regions namely; Khomas, Caprivi and Ohangwena. WFP provided food supplements to 525 OVCs in 2006 and 371 by May 2007 attending JFFLS. This project is designed specifically to empower orphans and other vulnerable children aged between 12 and 18 years living in communities highly impacted by HIV/AIDS. JFFLS impart agricultural knowledge, life skills, and provide the OVC with psychosocial support. Apart from supporting the JFFLS, FAO is also supporting government with training and capacity building on the linkages between gender, HIV/AIDS, food security and agriculture. The Community Led Action Against HIV/AIDS (CLAAHA) spearheaded by the MoAWF in Caprivi and Kavango regions involves communities fully in planning using participatory methodologies to identify viable projects to improve the lives of orphans, vulnerable groups and PLWHA. By the end of the two years project phase, 36 out of 120 communities managed to access support for CLAAHA Community Action Planning. 31 communities managed to take off with their 39 Kamwi.R, February

89 identified activities while five failed to commence. According to MoAWF the initiative was well received by the other communities as evidenced by the number of proposals received, requesting for support. Unfortunately, due to financial constraints, the project is slowly folding 40. The Churches Alliance of Orphans (CAFO) operates in all the thirteen regions. With a combined membership of 1.2 million, the largest number of beneficiaries are in the northern part of the country, which has 800,000 members. CAFO works through projects to reach the beneficiaries. These projects are able to access N$ 5000 to N$ 30,000 to carry out livelihood activities that would mitigate the impact of HIV on OVC and their affected families. The project has so far trained 145 caregiver/providers in OVC caring. There is high level sustainability in the sense that most of the self help projects are still running with minimal external support. So far the project has reached 5033 OVC from July 2006 to June The Catholic Aids Action is providing micro-projects for OVC and PLWHA and it has so far reached 4103 beneficiaries in Omusati, Oshana and Kavango regions. In order to assist the San people in the southern part of the country, the CAFO has introduced a Goat /Sheep project. The project provides training for the household head for 6 12 months on goat management. Upon graduation, 10 goats are donated to the family as a form of livelihood. So far, 7 families have benefited from the project bringing back pride and dignity. CAFO is also in the process of revitalising the vegetable garden in Kanene region, which was left by the Germans. The HIV/AIDS policy of Namibia and other policy documents such as the vision 2030 and the Second National Development Plan (NDP II) emphasise mainstreaming of HIV/AIDS in all developmental projects. This policy is also backed by collaborating partners support strategies. The office of the Prime Minister conducted an assessment on HIV/AIDS Mainstreaming within the Public Service Sector of Namibia with the aim of establishing the extent mainstreaming HIV/AIDS is incorporated into the core functions of each line ministry. The study reviewed that 17 (67 percent) out of 27 institutions visited had not yet implemented any of the eight recommended mainstreaming steps, seven (22 percent) had only implemented one to four, while only three (11 percent) had implemented between five and eight steps. In 2001, Cabinet approved cash for work, however, this policy has not been implemented. No reason was advanced for not implementing the activity. The National school feeding programme is concentrated in critical areas such as those with marginalised groups, small farm areas and high numbers of people working on farms. The programme is only for OVCs in primary school, selected using defined criteria. Both the schools and communities have shared responsibilities in the programme. Parents provide fire wood and water, and they do the cooking as well as serving the food, while one member of staff is assigned to ensure that the process moves well. Table 1 below tabulates the breakdown of beneficiaries by region against the total enrolment of the selected circuits. Table 4.1: National school feeding programme beneficiaries Total Enrolment in selected circuits Number of Beneficiaries %Beneficiaries 1 Caprivi Erongo Hardap Karas Kavango Khomas (MAWF, Newsletter, 2006). 89

90 7 Kunene Ohangwena Omusati Omaheke Oshana Shikoto Otjozondjupa TOTALS Source: Ministry of Education, 2007 NGOs and CBOs have taken up the challenge to reach OVC and provide assistance in terms of basic school requirements. Data available from NRCS indicate that, as at 2006, 30,000 OVC countrywide were registered, out of which 8000 benefited from school uniforms and school materials, and others were referred to relevant authorities for assistance. 20 orphans in Omaheke Region benefited from the UNAIDS small grant which caters for toiletries, school uniforms and food. 41 The Directorate of Extension and Engineering Services of the Ministry of Agriculture, Water and Forestry has been organising training courses aimed at empowering PLWHA project members in the area of vegetable production, marketing, water pump repairs and basic management skills e.g. Poperange vegetable project. MoAWF is promoting the hydropouric vegetable gardening which is less labour intensive and requires minimal water to grow. A number of CBOs and NGOs in Khomas region are using this initiative to reduce stress on PLWHA. At community level, the Namibia Network for AIDS Services Organisation (NANASO) has developed training materials which are being used by the majority of NGOs and CBOs engaged in nutrition and HIV/AIDS training. Being a coordinating body, NANASO has also conducted training of trainers on behalf of the various civic organisations in the area of nutrition as it relates to HIV/AIDS. Nutrition is also covered in the Home Based Care training package though the component is weak and this was reaffirmed by the AIDS Care Trust, one of the leading national NGOs engaged in HBC activities at community level. The Social Marketing Association with the help of NANASO has developed a recipe book which promotes local foods. The organisation is in the process of including food security activities in their programme. As an effort to empower families with good young child feeding practices, Ministry of Health has introduced cooking demonstration and nutrition education in three referral hospitals. This idea sprang from the fact that, there were too many readmissions of children that were previously treated for malnutrition. The MoRLGH is implementing safety net programmes such as food for work for an average of about 3000 beneficiaries per year. Red Cross in collaboration with MoAWF has been very instrumental in improving water at community level, focusing on rehabilitating water springs, foundations and wells. In 2006, 26 water points were constructed with a pump technology in the region of Kunene, to benefit a population of 4926 which has improved from 4057 in The impact has been seen in that, there are now permanent settlements and less water borne diseases. 42 However, Government, through the TB programme has identified lead NGOs in each region to undertake community TB programmes. There is evidence that some projects are performing very well in providing TB management services as 41 Summary issues on poverty, food security and nutrition, Multi-sectoral Regional Support Visit NRCS, Annual Report

91 close as possible to the patients. Below is the information captured from a project visited in Khomas region: Photos: Penduka TB Centre Penduka TB project, in Khomas region has about 500 TB patients who have been registered for a period of six months. They are provided with a meal alongside training in income generating activities and skills. The project also provides weekend food packages as support to very sick and under weight patients. In addition, the project also provide temporary employment to some former patients as TB and DOTs field promoters. Patients are monitored every day of the six months except weekends when food parcels are provided. All the 41 staff members at Penduka have undergone one or more trainings in TB management. The project has recorded success in TB management by reducing defaulter rate to about one percent. This is a success story that can be replicated to other regions. It is an expensive project to run but in the long term, it becomes cheaper because there are very few TB relapses. MGECW has expanded the staffing structure to include more social workers and clerks at National, Regional and constituency levels. The National Planning Commission is in the process of transferring five officers working on the Socio-economic integration of the ex-combatants programme to MGECW. Each region has at least one social welfare officer who is assisted by Record Clerks/Child Welfare Officers. The role of the Community Activator has been expanded to cover more of child welfare issues. HIV/AIDS and nutrition in the Ministry of Health and Social Services is addressed under the non-communicable diseases component. Training materials on HIV and Nutrition have been developed, though training on the new materials has only been conducted at the five Regional Training Centres due to limited human resource. The training is expected to cover all 13 Regions, with the hope of scaling up to the lower levels. According to the information obtained from the MoHSS, only 252 cadres have undergone the training. A total of 2,895 health workers have received training in HIV/AIDS treatment, care and support, which has nutrition as one of the components. Government, through MoHSS, has recruited a Technical Advisor to assist with pushing the agenda on Nutrition and HIV/AIDS forward. PMTCT training package has a small component on infant and young child feeding. However, the infant and young child feeding policy was developed in It provides guidance on how to manage an infant and young child in the area of feeding and counselling regardless of their HIV status. The IYCF guidelines and counselling cards are in draft form. Vitamin A is being supplemented to all children under five years regardless of HIV status, attending children s clinic, and to post partum mothers. Iodine 91