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AIDSTAR-One Namibia’s Prevention Planning Process


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In many countries facing high-prevalence, generalized HIV epidemics, the development of a national prevention strategy is difficult and often does not produce coordinated and comprehensive results. In …

In many countries facing high-prevalence, generalized HIV epidemics, the development of a national prevention strategy is difficult and often does not produce coordinated and comprehensive results. In Namibia's prevention planning process, these challenges were addressed using a combination prevention strategy tailored to local epidemiology and demographics. The development process was furthered by a strong sense of cooperation between Namibia's Ministry of Health and Social Services and staff at UNICEF and UNAIDS, as well as CDC and USAID (funded by PEPFAR).

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  • 1. AIDSTAR-One | CASE STUDY SERIES June 2011Namibia’s Prevention PlanningProcessSuccessful Collaboration for a NationalCombination HIV Prevention Strategy I n Walvis Bay, Namibia—one of the largest ports in Southern Africa—thousands of shipping containers line the shores between the sands of the Kalahari Desert and the Atlantic. Sailors and laborers flock to the harbor to find employment, and when the work day is done, they seek relaxation and entertainment on shore in their housing settlements, where bars offer a potent local brew and a place to meet women. It is not difficult to find young women who are willing to exchange sex Sam Clark for the modest things a dockworker’s money can buy: a pretty piece of jewelry, a pair of the must-have brand of jeans, a cell phone. But some ofTwo members of the Total Control them—occasionally girls as young as 14 years of age—will discover thatof the Epidemic community outreach these transactions can also lead to HIV infection.program work to motivate anantiretroviral defaulter to resumetreatment. In this setting, the aptly named Multipurpose Center offers a broad mix of HIV prevention services combining mutually supportive behavioral, biological, and structural interventions, all targeted to the local epidemiology. The Center—one of only a few of its type in Namibia—houses an HIV testing clinic, trains HIV outreach workers and community mobilizers to educate the surrounding community about HIV, offers condoms, and encourages individuals to come in for HIV testing and counseling. Other Center services include providing meals for orphans and vulnerable children, support groups for people living with HIV (PLHIV), home-based care and counseling, and groupBy Sam Clark and cultural and drama activities focusing on HIV prevention. The CenterSharon Stash also experiments with income-generation activities—a bike repair shop, gardening classes, a catering service, computer training, and a course in tailoring—to create economic opportunities for young women that CenterAIDSTAR-One staff hope will compete with the men at the port.John Snow, Inc.1616 North Ft. Myer Drive, 11th Floor This publication was produced by the AIDS Support and Technical Assistance ResourcesArlington, VA 22209 USA (AIDSTAR-One) Project, Sector 1, Task Order 1.Tel.: +1 703-528-7474 USAID Contract # GHH-I-00-07-00059-00, funded January 31, 2008.Fax: +1 703-528-7480 Disclaimer: The author’s views expressed in this publication do not necessarily reflect the views of the United Agency for International Development or the United States Government.
  • 2. AIDSTAR-One | CASE STUDY SERIESThe Center reflects how Walvis Bay’s potent array of • Linking prevention program activities to clinicalHIV drivers—alcohol, migrant work, intergenerational services.and transactional sex—requires a combination oftailored responses. The combination approach may Namibia’s experience illustrates the level ofavoid some of Namibia’s prevention pitfalls, such coordination needed to institute combinationas the unmet promise of more than a decade of prevention within a national program. The carefullybuilding national awareness. Despite near universal planned sequence of events that led to a nationalknowledge of HIV, high levels of vulnerability and risk prevention strategy also provided the impetus tobehavior persist. establish a National Technical Advisory Committee for Prevention (TAC/P) with a full-time coordinatorNamibia’s national prevention planning has started within the Namibia Ministry of Health and Socialthe process of coordinating prevention program Services (MOHSS)/Directorate of Special Programsdesign and implementation to ensure these (DSP). The TAC/P and its related technical workingmultiple drivers are tackled at the regional and groups provide ongoing guidance for focused,local levels. evidence-based interventions that address key factors influencing the epidemic. Some of the remaining challenges will be met over the comingCombination Prevention months, as Namibia undertakes the next phase of its planning process, the development of aProgramming comprehensive operational plan. All in all, Namibia’s prevention planning process provides a usefulNamibia has formulated a comprehensive national template for countries that want to implement acombination prevention strategy through a long- combination HIV prevention approach within high-term planning and advocacy process. Although a prevalence generalized epidemics.combination approach was not explicitly plannedat the time of its launch, Namibia’s 2010 nationalprevention program strategy is now firmly groundedwithin a combined prevention framework.Namibia’s prevention response illustrates several key Combination HIV preventionaspects of combination HIV prevention programming includes a mix of strategies andin a high-prevalence generalized HIV epidemic, risk-reduction approaches thatincluding: use current epidemiological• Using all available data to identify a wide range of and programmatic evidence to key factors that influence the epidemic, including target different audiences with biological, behavioral, social, and structural factors simultaneous behavioral, biomedical,• Tailoring prevention design to regional and social normative, and structural community-level contexts interventions that respond to local• Addressing structural issues, including gender, realities. alcohol abuse, and poverty2 AIDSTAR-One | June 2011
  • 3. AIDSTAR-One | CASE STUDY SERIESThe Origins of the approaching 80 percent of those in need, the momentum for treatment programs and for preventionPrevention Planning Process of mother-to-child HIV transmission programming was strong. Yet how could Namibia continue to afford theIn 2006, Namibia’s HIV prevalence was estimated costs of treatment? The country needed to find a wayto be among the highest in the world: 20 percent to slow the spread of HIV.among pregnant women aged 15 to 49 yearsattending antenatal care clinics. In response to thisalarmingly high prevalence and to serious perceived Technical Approachgaps in Namibia’s HIV prevention programs,a group of highly motivated technical advisors Namibia currently faces a generalized HIV epidemicfrom the MOHSS, the Joint U.N. Programme on that is primarily transmitted sexually. There areHIV/AIDS (UNAIDS), the U.N. Children’s Fund now suggestions of a decline in HIV prevalence. In(UNICEF), the U.S. Centers for Disease Control 2008 and 2009, a modeling exercise produced anand Prevention (CDC), and the U.S. Agency for estimate of national HIV prevalence of 13.3 percentInternational Development (USAID) collaborated to in the general population aged 15 to 49 years. Whiledevelop a systematic prevention planning process data from antenatal clinic surveillance suggestaimed at reducing the spread of HIV in Namibia prevalence among older women had increased,(MOHSS/DSP 2007). prevalence among younger women aged 15 to 19 had declined from 12 percent in 2000 to 5 percentCould Namibia’s prevention programs reduce this in 2008 (MOHSS/DSP 2010). But HIV prevalencehigh HIV prevalence? While the U.S. President’s varies greatly across the country’s 13 regions, fromEmergency Plan for AIDS Relief (PEPFAR) had 6 percent to 30 percent, with very high prevalence inbudgeted U.S.$19 million in fiscal year 2007 for the more densely populated areas along Namibia’sprevention in Namibia, the MOHSS itself was northern border. This variation presents a majorprimarily focused on treatment, care, and support. challenge: to tailor prevention programs to fit thisPrevention programming within the country was not wide range of regional prevalence.centrally coordinated; no single government agencywas responsible for prevention, and there was no Namibia’s HIV prevention program: Thepoint person for prevention within the MOHSS. national strategic response to HIV is guided by two key planning documents: the Medium Term Plan IIIThere also had been no effort to synthesize the for 2004-2009 and the newly completed Nationalfragmented evidence on the HIV epidemic in Namibia Strategic Framework (NSF) for 2010/11-2015/16and on factors driving HIV transmission as the basis (MOHSS/DSP 2010).1 The National AIDS Executivefrom which to develop a comprehensive national Committee (NAEC) is tasked with providingprevention strategy. After a decade of activities to overarching technical leadership, managementraise awareness of HIV, client populations had begun oversight, and coordination for the national HIVto “tune out” prevention messages, and revitalized program through multi-sectoral partners, while thebehavior change approaches were needed. MOHSS manages and coordinates the ongoing 1 The NSF was reviewed and approved by the National AIDS Committee, the high-The Namibian government also faced a funding est governmental policymaking body on HIV. It was approved by the Cabinet anddilemma. With antiretroviral (ARV) coverage received final approval by the Parliament of Namibia on Worlds AIDS Day 2010. Namibia’s Prevention Planning Process: Successful Collaboration for a National Combination HIV Prevention Strategy 3
  • 4. AIDSTAR-One | CASE STUDY SERIESimplementation of the national HIV response through partners, including the Total Control of the Epidemicthe DSP. Namibia’s regions coordinate their efforts Program of Development Aid for People to People.through Regional AIDS Coordinating Committees This community-based effort educates hundredsand at the local township level. of thousands of community members about HIV prevention and links them to appropriate prevention,Among other activities, the national program has care, and treatment services.engaged in large-scale efforts to distribute freecondoms and to provide HIV counseling, testing, Namibia’s internationally recognized success inand referral services in most regions. Programs rapidly expanding access to ARVs to more thanreach out to different populations, such as residents 80 percent coverage plays a role in the nation’sof nature conservancies, agricultural workers, high- prevention efforts. Supported by the nationwiderisk transport workers, and the nation’s educators, network of counseling, testing, and referral services,among others. PEPFAR has provided funding the government provides antiretroviral therapyfor a variety of prevention programs in Namibia, (ART) at all hospitals and health centers and atincluding support for a full-time prevention advisor some of the larger clinics (LeBeau and Yoderposted within the MOHSS/DSP, technical support 2008). Based on the emerging recognition of theadvisors for blood safety and medical injection immunosuppressive effects of ART, there is growingsafety programs, and a range of implementing recognition that “ARV treatment as prevention” BUILDING CAPACITY FOR COMBINATION PREVENTION Since 2008, the Communication for Change (C-Change) prevention programs to include evidence-based Program, which is funded by PEPFAR through USAID, programming, combined prevention including combined has used a combination prevention approach to behavior change related to the drivers of the epidemic, strengthen Namibian behavior change communications and provision of or links to biomedical and structural using a tailored program for building capacity for more interventions” (C-Change 2010, 1, emphasis added). than 20 local organizations. Source: C-Change 2008, 2010 Because levels of knowledge about HIV are generally quite high, organizations were encouraged to focus on addressing the main drivers of the epidemic (e.g., high rates of multiple and concurrent partnerships) while providing linkages to other biomedical and structural interventions. Using a participatory process, C-Change assessed the behavior change communication efforts of all youth, workplace, and community prevention programs, Sam Clark focusing on organizations’ core competencies in program design, implementation, and monitoring and evaluation. A program for building capacity was tailored The staff of a local community-based organization, Caprivi Hope for Life, received training in early 2010 to address the specific needs of each organization. in the use of C-Change’s interpersonal communication This enables partners to “refocus their current HIV materials on multiple and concurrent partnerships.4 AIDSTAR-One | June 2011
  • 5. AIDSTAR-One | CASE STUDY SERIEScan fit into a combination approach to prevention.2 3. Identification of global best practices in preventionNamibia’s presumed decline in HIV incidence maybe associated with three main factors: 1) reduction 4. A national consensus meeting to permitin risk behaviors leading to fewer new infections; stakeholders to consider and discuss the findings2) pool saturation, where those most likely to be of the earlier steps and to develop an appropriateinfected have already been infected; and 3) high prevention responseART coverage, which has reduced viral load andthus infectivity (MEASURE Evaluation and USAID/ 5. An NPS and budgeted action plan based on theNamibia 2009). outcomes of the prior four activities. Ultimately, some of these five key steps were notInitiating the Prevention implemented as planned, but for a first-time nationalPlanning Process prevention planning process, the initiative was a promising if imperfect effort. The proposal tookThe concerted advocacy to scale-up prevention regional participation seriously. The planned situationbegan in 2006 with an ad hoc Prevention Working assessments included workshops with regionalGroup made up of technical advisors working within delegates to assess drivers of the epidemic at regionalthe MOHSS/DSP and a range of development levels. The response analysis intended to mappartner agencies, including UNICEF, UNAIDS, prevention activities at the regional level in collaborationThe Deutsche Gesellschaft für Internationale with the Regional AIDS Coordinating Committees.Zusammenarbeit, PEPFAR, CDC, and USAID.Members developed a close and collegial rapport. NAEC approved the proposal, and the U.S.$450,000Through their participation in regular NAEC cost was shared by UNAIDS, UNICEF, and USAID.meetings, Prevention Working Group members held PEPFAR supported the situation assessmentsa forum to discuss emerging findings on the drivers and response analysis conducted by MEASUREof the HIV epidemic and build political will for a Evaluation, as well as costs for drafting thegreater emphasis on prevention. NPS. Early in 2008, the MOHSS agreed to the development of a scope of work for a nationalStrategic sequence of steps toward the prevention coordinator funded by PEPFAR toNational Prevention Strategy (NPS): In increase the capacity within the MOHSS/DSP toSeptember 2007, the Prevention Working Group move this ambitious planning process forward.proposed a planning process for developing anational prevention strategy under the supervision of Addressing major structural factors: As partthe MOHSS/DSP (MOHSS/DSP 2007). The process of the prevention advocacy process, in 2008 PEPFAR/included five steps: Namibia successfully competed for special USAID1. Situation assessments to identify the drivers of the pilot initiative funding to address two major structural epidemic and key contextual issues factors within Namibia’s HIV epidemic: alcohol and gender. A full-time MOHSS staffer now leads an2. A response analysis to understand Namibia’s Alcohol Technical Working Group with PEPFAR-funded current investments in prevention programs technical assistance and human resources support. Gender is a cross-cutting theme within Namibia’s NSF2 Studies in diverse settings indicate that wider treatment is associated with fewer for 2010 to 2014, and the 2010 National Testing Daynew HIV infections. See theme was “Engage men for testing.” Namibia’s Prevention Planning Process: Successful Collaboration for a National Combination HIV Prevention Strategy 5
  • 6. AIDSTAR-One | CASE STUDY SERIES The Five Steps of the The key drivers to emerge from the analysis covered the full range implicit in a combination prevention­Planning Process approach:Step 1—Conduct a situation analysis • Biological: Lack of male circumcisionto identify and map the drivers of theepidemic: The situation analysis resulted from • Behavioral: Multiple and concurrent partnershipsclose collaboration between monitoring and (MCP), inconsistent condom use, and excessiveevaluation (M&E) technical advisors within the alcohol useMOHSS, DSP, UNAIDS, PEPFAR, and analysts atMEASURE Evaluation. This collaboration paid off by • Social: Norms governing the expected rolesensuring that the data, despite limitations, were used of men and women, the formation of sexualeffectively and to the fullest extent feasible. Data partnerships, and marriage, which togetherfrom multiple sources were triangulated to identify create an environment for intergenerational andthe drivers most likely to contribute to the spread of transactional sexHIV at the national and regional levels (de la Torre etal. 2008). The analysis identified the most common • Structural: Migration, changing marital patterns,risk behaviors, characteristics associated with higher and poverty.risk behavior and testing positive for HIV, and keyregional differences in biomedical, social, and sexual Step 2—Mapping Namibia’s preventiondrivers. A major constraint was the absence of efforts: The prevention planning process wasbiomarker data in the 2006 to 2007 Namibia National supposed to map Namibia’s ongoing preventionDemographic and Health Survey, which precluded programs to be published as a companion documentestablishing correlations between HIV and behavioral with the drivers document. Due to contractualdata (MOHSS and Macro International 2008). A problems, this second step was not completed. Thisparallel qualitative situation analysis was conducted, gap has yet to be filled and illustrates the limitationsfocusing on two likely drivers of the HIV pandemic: of the planning process.alcohol and concurrent partnerships (LeBeau andYoder 2008). Step 3—Identification of global best practices in prevention pertinent toThe “drivers document,” drafted by MEASURE Namibia: This step was implemented, with supportEvaluation (de la Torre et al. 2008), was from UNAIDS, by having a global expert on HIVtransformative. It summarized the quantitative prevention, Professor Marie Laga, develop a surveyanalysis and created regional profiles of key factors of the evidence for different prevention prioritiesassociated with the epidemic. The analysis literally and what has worked in other regions (Laga 2008).put the drivers on the map, plotting key indicators A UNAIDS prevention taxonomy document, whichfor various drivers in all 13 regions by gender and summarized global priorities, was developedsuccinctly summarizing the findings at the national and used as a guide to help the development ofand regional level. The document generated a prevention strategies, but was not published.commitment to evidence-based prevention strategiesand underscored the need for regionally tailored Step 4—Build a broad national consensusprograms instead of one uniform national approach. on prevention: Namibia’s First National PreventionThis tailoring is fundamental to combination Consultation was convened in November 2008 byprevention. the MOHSS (MOHSS and UNAIDS 2008). Thanks6 AIDSTAR-One | June 2011
  • 7. AIDSTAR-One | CASE STUDY SERIESto careful preparation by Prevention Working Group Step 5—Complete the strategy document:members, there were over 130 participants, ranging The first draft of this important document wasfrom the most senior ministry officials from MOHSS completed in November 2009, but the finaland the Ministry of Information and Communication completion of the NPS was on hold until the NSFTechnology and several other ministries, as well was approved (MOHSS/DSP and TAC/P 2009).as participants from the regional level including The TAC/P plans to use the draft NPS as a basisseveral regional governors and a majority of the 13 to operationalize the final NSF with detailed coreRegional AIDS Coordinators. Representatives of all strategic matrices, budgeted workplans, and M&Eof the major development partners and implementing plans corresponding to each of the drivers that thenongovernmental organizations (NGOs) attended. NSF has selected as a priority.The two-day consultation had three main objectives:to identify likely drivers of the epidemic, to reachconsensus on HIV prevention priorities, and toidentify HIV prevention strategies to be included in Roles and Responsibilitiesthe next NSF. An additional goal was to strengtheninter-ministerial and multi-sectoral coordination. From ad hoc Prevention Working Group toUsing participatory approaches (see section on TAC/P, a milestone for national prevention:“How the National Consultation Prioritized the Key Shortly after the national consultation, a nationalDrivers of the Epidemic”), the consultation meeting prevention coordinator began work. Over a periodsucceeded in both meeting these immediate of months, the NAEC approved a formal Terms ofobjectives and providing the impetus for important Reference to officially establish the TAC/P, with theinstitutional change. goal of providing “guidance and coordination on HOW THE NATIONAL CONSULTATION PRIORITIZED THE KEY DRIVERS OF THE EPIDEMIC Day One (November 5, 2008): The situation analysis results were presented with regional maps for each driver. Presentations were made on some of the major drivers: alcohol, MCP, most-at-risk populations, and male circumcision. From a list of 17 drivers, participants selected five: alcohol use, MCP, inconsistent condom use/unprotected sex, transactional sex, and lack of HIV testing and knowledge of status. Participants also identified five cross-cutting issues as important considerations for each priority driver: cultural and social norms, gender roles, mobility patterns, specific target groups (e.g., prisoners and men who have sex with men), and stigma and discrimination. Day Two (November 6, 2008): The following day included small group breakout sessions on each of the five drivers. Each group suggested intervention ideas using a three-step approach: identify target populations for their driver, determine suitable outcomes for the population, and recommend interventions for each of these outcomes at the environmental, community, and individual levels. Participants generated new intervention ideas for the five drivers, discussed and prioritized prevention strategies, and made recommendations for the new national prevention strategy. Overall recommendations included improving collaboration across government and civil sectors, and between national and regional levels; increasing access to services through outreach and mobile activities; and conducting additional research, especially among most-at-risk populations. Source: MOHSS and UNAIDS 2008 Namibia’s Prevention Planning Process: Successful Collaboration for a National Combination HIV Prevention Strategy 7
  • 8. AIDSTAR-One | CASE STUDY SERIESNamibia’s HIV prevention strategy development and The TAC/P facilitates an integratedimplementation, ensuring an integrated, harmonized, approach: A wide range of preventionand comprehensive approach” (MOHSS/DSP stakeholders participate in the monthly TAC/P2008, 1). A major milestone in national prevention meetings and the TAC/P attendance list for 2010promotion, the Terms of Reference explicitly included more than 70 representatives fromauthorizes the TAC/P to work on seven areas: sexual 35 agencies. Agencies included key Namibiantransmission (sexually transmitted infections, risk ministries, major national NGOs representingbehaviors); medical transmission (injection and PLHIV and HIV service agencies, major multilateralblood safety, biosafety); facility-based strategies; agencies, key local prevention implementingcommunity- and workplace-based strategies; mass agencies, bilateral international agencies, andmedia strategies to change social norms; initiatives international HIV agencies.targeting most-at-risk populations, includingprevention for PLHIV; and factors that exacerbate the Prevention technical working groups:epidemic (gender norms and alcohol). The TAC/P provides a supportive environment that advises and facilitates the work of technicalThe TAC/P’s overall responsibilities cover the working groups. While some of these groups actuallyfull range of activities required for a combination preceded the formal establishment of the TAC/P,prevention program: giving technical guidance during most now work collaboratively under the aegis ofthe development of an NPS, as well as technical the TAC/P. Group members attend the meetings ofoversight during implementation; guiding the process other groups, and groups submit documents to eachfor establishing the local evidence base for HIV other for comments. Coordination is achieved byprevention; developing prevention goals, strategies, cross-attendance and by circulating documents forand targets to be integrated within the NSF for 2010 2014; and establishing working groups on specificprevention topics. The TAC/P’s active role in the completion of the NSF: The TAC/P plays a central role in national planning decisions for prevention and provides essential guidance for the NSF. The prevention section of the NSF incorporates all key aspects of the TAC/P’s draft NPS and includes the TAC/P Terms of Reference mandates for prevention activities. The NSF is guided by the draft NPS’ combination prevention conceptual framework (see Figure 1). While this figure is somewhat inexact in the use of terms, it provides a practical visual outline for the combination prevention approach, showing the simultaneous roles of behavioral, structural, and biological interventions. Sam Clark Program ResultsTwo members of a community-based supportorganization who implement HIV behavior changeprograms for remote rural residents of nature Program objectives achieved: The planningconservancies in northern Namibia. process has met most of the goals outlined in the8 AIDSTAR-One | June 2011
  • 9. AIDSTAR-One | CASE STUDY SERIES FIGURE 1. NAMIBIA’S COMBINATION PREVENTION STRATEGY FRAMEWORK Reduction of HIV incidence to below a threshold level Reduction of exposure Changes in structure, or Biomedical to possible HIV through the enabling environment interventions to reduce changes in sexual to ensure access to HIV probability of HIV behavior prevention programs transmission • Medical male • Gender norms circumcision • MCP • Alcohol abuse • Prevention of • Early sexual • Decline in marital mother-to-child debut and co-habiting transmission • Inter-generational unions • Post-exposure sex • Gender prophylaxis • Low and inequalities • HIV testing and inconsistent • Mobility and counseling condoms use migration • Prevention of • Most at risk and • Education sexually vulnerable groups • Poverty/income transmitted inequality infections • Stigma • Blood safety • Condom use Source: MOHSS/DSP 2010 (Source: MOHSS/DSP 2010)September 2007 proposal, including the overall The prevention planning process led to anobjective of increasing national commitment to MOHSS agreement to hire a national preventiona refocused prevention strategy. The situation coordinator for a formally recognized TAC/P withanalysis provided useful findings on the important a comprehensive prevention mandate. The TAC/Pdrivers of the epidemic and contextual factors. serves a constructive role guiding the developmentThe participatory process of the national planning of the NSF and provides a forum to share andconsultation was highly inclusive. While still a coordinate prevention strategies at the national level.draft, the NPS was instrumental in guiding thedevelopment of the NSF and many of its ideas Program objectives not yet achieved:were ultimately incorporated into the framework. Because of contractual problems, the mapping of Namibia’s Prevention Planning Process: Successful Collaboration for a National Combination HIV Prevention Strategy 9
  • 10. AIDSTAR-One | CASE STUDY SERIESongoing prevention programs was not completed. coordinating activities for more coherent strategicThis has impeded the proposed involvement of interventions, and avoiding duplication of effort. Anregions in mapping the response and developing active TAC/P member working within the MOHSSregional prevention strategies. The final objectives pointed out, “We learn more about the civil societyand a budgeted national prevention action plan outside of the [Ministry of Health].” A seniorare still pending, but substantial progress is being prevention expert remarked, “I used to think I knewmade in this direction as Namibia undertakes the what others are doing. Now I know more. Everydevelopment of a Roadmap for the Implementation of month we get new ideas.” Some stakeholdersHIV Prevention in spring and summer of 2011. have concerns about how to move from sharing to implementation and how to coordinate and planGetting traction—the following are parallel efforts to address multiple drivers. Othersexamples of how national prevention recommend that the TAC/P should have a budgetplanning translates into program practice: and that the coordinator position be on a higher administrative level so as to have more influence• The drivers document: Although not universal, within the MOHSS. there appears to be widespread approval of the drivers document among Namibia’s prevention • The NPS: There is near universal support among stakeholders, most of whom are familiar with at prevention stakeholders for the draft National least two or three drivers at both the national and Planning Strategy. Some are disappointed about regional levels. Some stakeholders feel more how long it has taken to draft the NPS and emphasis should be given to gender, gender expressed concern about the possible redundancy norms, and stigma, while others, including the in having two national-level strategic documents, Global Fund to Fight AIDS, Tuberculosis and the NSF and the NPS. Malaria, feel it should be structured around risk groups rather than drivers. What Worked Well• The National Prevention Consultation: Stakeholders who participated in the event felt Collegiality: While it may appear self-evident, it was a major step toward consensus on the subjective, and too elusive to be replicable, it is drivers and prevention strategies, as well as an nonetheless noteworthy that, due in part to strong opportunity to share ideas, get input from regional rapport, senior prevention and M&E staff at the CDC, representatives, and build impetus for prevention MOHSS, UNICEF, UNAIDS, and USAID developed programs. They felt it was an important transition, close working relationships. Many coordinating and was the first time that prevention strategies bodies in countries throughout the world struggle to had been shared. achieve a similar level of collegiality and cooperation.• The TAC/P: Virtually all prevention stakeholders An exceptional situation analysis: The are aware of and actively participate in the TAC/P, situation analysis was a success due to the including representatives of organizations and concerted effort by M&E technical advisors to ensure agencies for PLHIV and the private sector. The a thorough analysis of limited data. By insisting on few agency representatives who were not aware mapping the drivers of the epidemic at the regional of the TAC/P expressed interest in participating. level, these advisors developed a document that Many express an extremely positive view of captured the attention of the national HIV prevention the TAC/P as a mechanism for sharing ideas, community. It was also exceptional because of the10 AIDSTAR-One | June 2011
  • 11. AIDSTAR-One | CASE STUDY SERIESactive role of country-level HIV program staff; it was not, as usuallyhappens, dominated by staff outside of the country. HOW DOES NAMIBIA’S PREVENTIONAn effective national prevention consultation: The two-day PLANNING PROCESSmeeting generated the impetus to implement the next steps. Without DEMONSTRATEit, stakeholders might still be discussing what needs to be done in A COMBINATIONNamibia. It ensured that the results of the studies and the importance PREVENTIONof prevention were on the agenda of senior MOHSS staff. Finally, it APPROACH?provided a consensus that encouraged prevention stakeholders to • By using evidence towork together. target prevention activities addressing social, economic,Providing guidance to the NSF through 2016: The TAC/P and cultural drivers ofis an important national prevention resource and plays a central role transmissionin developing the prevention components for the NSF. By virtue ofits diverse membership of HIV prevention agencies, it can provide • By including a combinationcoordinated technical leadership for all components of the NSF, including of risk reduction approachesblood safety, prevention for PLHIV, male circumcision, and alcohol (biomedical, behavioral, andabuse. structural) • By linking program participantsCoordination of national social and behavioral change to diagnostic and treatmentstrategies for key epidemic drivers: The TAC/P and the MCP servicesTechnical Working Group have been instrumental in the developmentof national behavior change campaigns implemented by experienced • By engaging appropriatelead agencies with coordinated, evidence-based approaches. The leaders and decision makers“Break the Chain” Campaign to address MCP has broken new ground • By strengthening capacity toby using standardized, multilevel, multichannel approaches with mass manage prevention and interpersonal communication materials. The TAC/P’sAlcohol Technical Working Group recently replicated this approach foralcohol and HIV.ChallengesCoordinating a combination prevention portfolio: The processof simultaneously developing responses for multiple drivers, such as MCP,alcohol, and male circumcision, is a major challenge. A work planningprocess to phase in and set priorities for activities can help achieve alocally tailored balance.Avoiding a donor-driven process: Initially, there was concernthat the planning process would end up being donor-driven withoutbeing endorsed by key national stakeholders, especially the MOHSS.Gradual evidence-based advocacy achieved ownership among allstakeholders. Namibia’s Prevention Planning Process: Successful Collaboration for a National Combination HIV Prevention Strategy 11
  • 12. AIDSTAR-One | CASE STUDY SERIESBuilding capacity and participation in coordination to ensure the best sequence of activitiesprevention at the regional and local level: for maximum synergy.The prevention planning process sought genuineregional participation, but the expected regional Mapping the response: There may still befollow-up to map prevention programs for local a need to inventory and map existing preventioncommitment did not take place. programs and services to identify gaps and opportunities at both the national and regionalGetting prevention players coordinated levels. It is clearly important to map the preventionand aligned: Namibia has traditionally relied on programs that have been developed, especially for athe Ministry of Information and Communication combination prevention approach, where messagesTechnology to roll-out national communication and partners need to be coordinated and targetedcampaigns, yet the TAC/P is housed within the appropriately.MOHSS. Bridging traditional boundaries betweenline ministries is a long-term challenge. Follow-up at the regional level: The original plan was for the regions to somehow develop their own assessment of local drivers and developTAC/P gaps in membership: There are still their own tailored responses. Especially in high-some important gaps in the membership of the prevalence regions, a prevention coordinationTAC/P, such as the Voluntary Counseling and structure at the regional level, with regional quarterlyTesting Technical Working Group and the PEPFAR- meetings, may help build local ownership andfunded through USAID Safe Injection Program. encourage “home-grown” strategies. Prevention programs with PLHIV:Future Programming Representatives from several agencies advocated for more work to expand and enhance programsNational prevention roadmap: In spring, by and for PLHIV, including treatment literacy and2011, through the involvement of the MOHSS, development of personal prevention plans.the TAC/P is spearheading the developmentof a Roadmap for the Implementation of HIV The value of a truly multi-sectoralPrevention. This comprehensive implementation approach: Despite excellent progress,strategy will focus on the “who, how, where, prevention programming remains closelyand when” of achieving a balanced combination allied with just the MOHSS and the Ministry ofprevention approach. The Roadmap aims to Information and Communication Technology. HIVprovide the necessary foundation for systematic prevention programs need a greater mandatescale-up of services. within other line ministries, which are often not as responsive.Future management challenges: The TAC/Pmust devise a coordination process that worksfor a large number of driver-specific prevention Recommendationsactivities. The competing demands of scaling upmultiple prevention initiatives to address such diverse Collaborate across multilateral anddrivers as stigma, MCP, alcohol abuse, and male bilateral boundaries: The Namibiancircumcision will require concerted planning and experience demonstrates how diverse agencies,12 AIDSTAR-One | June 2011
  • 13. AIDSTAR-One | CASE STUDY SERIESmultiple government ministries, UNAIDS, in building a combination prevention approach. AUNICEF, USAID, and PEPFAR can share ideas well-designed prevention plan can be rolled out toand resources to develop a common agenda for strengthen the national prevention infrastructure.prevention. To do this, the planning process takes a step back from what is usually done (developing plansBuild good working relationships: The for specific risk groups) and instead addressesextraordinary rapport that helped launch Namibia’s social and economic drivers, using an evidence-prevention planning process is highly subjective and based approach. The process should take placenot easily replicated. Organizational development in a consultative, participatory environment toefforts to establish interagency collegiality may be achieve group commitment among stakeholdersnecessary. for a combination prevention policy. Since the time Namibian prevention planning process was initiated, appreciation of and experience with theEngage appropriate leaders and decision combination prevention approach have grownmakers at all levels: The prevention worldwide. As a result, it may be easier to make theconsultation made an unprecedented effort to case for replicating Namibia’s planning approach ininclude the full range of national and regional countries that lack an adequate national preventionleadership. The ongoing TAC/P membership is infrastructure. nextremely inclusive.Strengthen management capacity for RESOURCESprevention programs: The roll-out of theC-Change prevention capacity assessment Alcohol Consumption, Sexual Partners, and HIVprocess, followed by training for building capacity Transmission in Namibiaand support for combination prevention project, has reached a wide range of agencies cfm?id=950&srchTp=homeworking in prevention. C-Change Strengthening Capacity in SBCCInvest in highly qualified senior leadership Programmingwith high motivation and experience: The planning process was long-term, with a HIV/AIDS in Namibia – Behavioural and Contextualphased sequence of activities that required constant Factors Driving the Epidemicoversight and commitment. It had the benefit of highly qualified, experienced, and committedcadre of M&E and prevention staff as well as local National Strategic Framework for 2010/11-2015/16implementing partners. Duplicating Namibia’s planning process will require comparable namibiaexperience and commitment. Report of the First National Consultation on HIVReplicate the Namibian planning Prevention in Namibiaprocess: Namibia’s experience shows that strategic planning can make a difference PreventionReport_v4%20FINAL.pdf Namibia’s Prevention Planning Process: Successful Collaboration for a National Combination HIV Prevention Strategy 13
  • 14. AIDSTAR-One | CASE STUDY SERIESTAC/P Terms of Reference MOHSS/DSP. 2008. Technical Committee for HIV Prevention. Unpublished formalnamibia Terms of Reference for the TAC/P. Windhoek, Namibia: MOHSS.REFERENCES MOHSS/DSP. 2010. National Strategic Framework for HIV and AIDS. Windhoek: MOHSS/DSP.C-Change Namibia. 2008. NACSO HIV andAIDS Program: HIV and AIDS Behavior Change MOHSS/DSP and TAC/P. 2009. Namibia NationalCommunication Assessment and Recommendations Strategy for the Prevention of Sexual Transmissionfor COP08. Windhoek, Namibia: C-Change. of HIV 2009-2014. Draft document developed by theC-Change Namibia. 2010. C-Change Namibia TAC/P. Windhoek, Namibia: MOHSS/DSP.Partner Strengthening Approach. Unpublished project MOHSS and Macro International. 2008.document. Windhoek, Namibia: C-Change Namibia. Namibia Demographic and Health Survey 2006-de la Torre, C., S. Kahn, E. Eckert, J. Luna, T. 07. Windhoek, Namibia: MOHSS and MacroKoppenhaver. 2008. HIV/AIDS in Namibia – International.Behavioural and Contextual Factors Driving the MOHSS and UNAIDS. 2008. Report of the FirstEpidemic. Windhoek, Namibia: MOHSS/DSP, National Consultation on HIV Prevention in Namibia.USAID/Namibia, MEASURE Evaluation. Available Safari Court Hotel, Windhoek, Namibia, Novemberat 5-6. Windhoek, Namibia: MOHSS and UNAIDS.(accessed March 2010) Available at, M. 2008. “Strengthening Prevention.” PreventionReport_v4%20FINAL.pdf (accessedPowerPoint presentation at the National March 2010)Prevention Consultation in Namibia, November 5.Available at ACKNOWLEDGMENTSPreventionReport_v4%20FINAL.pdf (accessedMarch 2010). The authors wish to acknowledge the many agencies and individuals who supported theLeBeau, D., and P. S. Yoder. 2008. Alcohol planning and implementation of this case study.Consumption, Sexual Partners, and HIV The development of this case study was supportedTransmission in Namibia. Calverton, MD: ICF Macro. by the members of the PEPFAR Technical WorkingAvailable at Group on Prevention for the General Population andcfm?id=950&srchTp=home (accessed March 2010) Youth and especially Timothy Mah, USAID. ThanksMEASURE Evaluation and USAID/Namibia. 2009. to the several individuals who were central to the“Major Factors Driving the HIV Epidemic in Namibia.” actual prevention planning process in Namibia andPresentation made in Windhoek, Namibia, August 20. who provided us with salient information: Todd Koppenhaver and Mary Furnivall, both formerly withMOHSS/DSP. 2007. Proposal for the Development the HIV/AIDS and Health Office, USAID/Namibia;of a Draft Prevention Strategy Based on a Review Rushnan Murtaza, UNICEF; Mary Mahy, formerlyof the Drivers of the Epidemic. Unpublished draft. of UNAIDS/Namibia; Claire Dillavou, formerly of(Kindly provided by R. Murtaza, U.N. Children’s CDC/Namibia; Nick DeLuca, CDC/Namibia; andFund, April 2010.) Frieda Katuta and Dietrich Remmert, DSP, MOHSS.14 AIDSTAR-One | June 2011
  • 15. AIDSTAR-One | CASE STUDY SERIESThanks also to Melissa Jones, Karla Fossand, members of the Technical Advisory CommitteeBrad Corner, and Dr. Didier Mbayi Kangudie, HIV/ for Prevention. At the regional level, we wish toAIDS and Health Office, USAID/Namibia; Michaela acknowledge the support of the Caprivi RegionalClayton, AIDS and Rights Alliance for Southern AIDS Coordinating Committee coordinator, theAfrica; Henk Van Renterghem, UNAIDS; Aune Caprivi Project Hope coordinator, the Director ofVictor and Sircca N. N. Vatuva, Department of Total Control of the Epidemic DAPP Caprivi, andDefense HIV/AIDS Project; Elizabeth Burleigh, local implementing agencies, as well as members ofC-Change Namibia (Academy for Educational the Erongo Regional AIDS Coordinating Committee,Development); Ian Maxwell and Otilie Lamberth, the Erongo HIV/tuberculosis coordinator, and localPACT, Namibia; Nahum J. Gorelick, NawaLife implementing agencies.Trust; Pamela Onyango, Namibia Global FundProgramme; Steven Neri, Project Hope, Namibia;Zacch Akinyemi, Family Health Association; RECOMMENDED CITATIONJane Shityuwete, LifeLine/ChildLine Namibia; Clark, S., and S. Stash. 2011. Namibia’s PreventionLibet Maloney, IntraHealth International; Kirsten Planning Process: Successful Collaboration for aMoeller Jensen, Development AID People to National Combination HIV Prevention Strategy. CasePeople Namibia; Casper W. Erichsen, Positive Study Series. Arlington, VA: USAID’s AIDS SupportVibes; Ingrid de Beer, PharmAccess; Peter J. van and Technical Assistance Resources, AIDSTAR-Wyck, NABCOA; Dr. Aziz O. Abdallah, University One, Task Order 1.Research Corporation Health ImprovementProject; and Velia Kurz, Namibian Association of Please visit forCommunity Based Natural Resource Management additional AIDSTAR-One case studies and otherSupport Organizations. Thanks also to the HIV- and AIDS-related resources. Namibia’s Prevention Planning Process: Successful Collaboration for a National Combination HIV Prevention Strategy 15
  • 16. AIDSTAR-One’s Case Studies provide insight into innovative HIV programs and approachesaround the world. These engaging case studies are designed for HIV program planners andimplementers, documenting the steps from idea to intervention and from research to practice.Please sign up at to receive notification of HIV-related resources,including additional case studies focused on emerging issues in HIV prevention, treatment,testing and counseling, care and support, gender integration and more.