USAID HIV Clinical Services Technical Assistance Project

Namibia Improves HIV Care through Training and High-Quality Services

kseaton — Fri, 16 Oct 2020 17:10:10 +0000

Namibia Improves HIV Care through Training and High-Quality Services kseaton October 16, 2020 October 16, 2020

Between 2015 and 2019, IntraHealth International’s USAID HIV Clinical Services Technical Assistance Project (UTAP) helped 42,578 HIV-positive clients in Namibia begin antiretroviral therapy (ART), conducted a nurse training program, increased the number of community adherence groups from 40 to 484, and helped roll out an electronic patient management system for the country.

In 2018, an estimated 200,000 people were living with HIV in Namibia, with regions in the north and capital city having the highest burden. Now Namibia is one of three sub-Saharan African countries that have achieved the UNAIDS 90-90-90 fast-track targets; still HIV/AIDS remains the country’s number one cause of death and disability.

With support from the US Agency for International Development, UTAP worked in eight districts and 77 sites, testing 461,020 individuals for HIV and connecting HIV-positive clients with ART within seven days of diagnosis.

By September 2019, 42,578 individuals were receiving ART and the rate of same-day ART initiation for new HIV-positive patients in eight high-volume facilities had increased from 15% in 2016 to 82% in 2019. 

A breakthrough in client-centered HIV care

UTAP focused on client-centered HIV care to better address clients’ preferences and reduce costs associated with frequent visits to health facilities at a time when such client-centered service delivery approaches were rare.  

Community adherence groups brought together people living with HIV who are on ART so they could offer each other support, advice, and encouragement to stay on their treatment regimens. The groups also helped health facilities retain their clients. Between 2017 and 2019, UTAP helped increase the number of community adherence groups (CAGs) from 40 to 484, serving 4,154 clients.

In 2018, UTAP started providing HIV testing services in the emergency room in five hospitals. Between 2018 and 2019, 2,598 individuals were tested for HIV in emergency rooms.

UTAP conducted districtwide trainings for health workers in all eight districts on provider-initiated HIV testing and counseling (PITC) and HIV rapid testing in hospital departments and facilities. The project shortened the training curriculum from five days to two-and-a-half and conducted trainings at district hospitals rather than at offsite venues. These changes reduced training costs, increased the number of health workers trained, and improved testing and diagnosis of new HIV positive cases from 60% in 2015 to 90% in 2018 and 2019.

In addition, the project trained a team of district trainers who now conduct ongoing training and mentorship.

Digital technology for better data

UTAP supported Namibia’s Ministry of Health and Social Services in rolling out IntraHealth’s redesigned electronic patient management system (ePMS) to provide the ministry with current and accurate patient data. ePMS now measures the continuity of care—from HIV testing to initiation on ART and continuous adherence on treatment.

By July 2020, the system was being used in 180 health facilities by 225 staff and is continuing to expand. 

A new training technique

To build health workers’ skills and make ART services more widely available, UTAP began conducting districtwide trainings in nurse-initiated management of ART (NIMART), certification, and ongoing mentorship for nurses based in primary health care facilities and various hospital departments. UTAP provided facilities with technical assistance to prepare and maintain NIMART sites for long term ART management.

UTAP also contributed to these successes:

Three district hospitals provided cervical cancer screenings to 1,413 women on ART in 2019.
Between 2018 and 2019, project-supported sites initiated 6,551 individuals on preexposure prophylaxis.
During 2016-2018, 72,838 pregnant women attended antenatal care visits in UTAP-supported health facilities.
By September 2019, 91% of clients on ART were screened at least once for TB within a six-month period.

IntraHealth’s USAID HIV Clinical Services Technical Assistance Project (UTAP) in Namibia was funded by the US Agency for International Development (USAID) through the President’s Emergency Plan for AIDS Response (PEPFAR).

Namibia HIV & AIDSA patient holds antiretroviral medications at a health facility in Northern Namibia. Photo for IntraHealth International by Morgana Wingard.USAID HIV Clinical Services Technical Assistance Project

HIV Support Groups Help Members and Health Facilities Alike in Namibia

kseaton — Tue, 26 Nov 2019 15:28:54 +0000

HIV Support Groups Help Members and Health Facilities Alike in Namibia kseaton November 26, 2019

December 06, 2019

Community groups keep each other accountable and healthy while living with HIV.

It is a sunny day at Korokoko village in Northern Namibia where the USAID HIV Clinical Services Technical Assistance Project (UTAP) is working to help people who live with HIV reach viral suppression.

Gathered under a tree are seven women and two men, including a community health worker and the district HIV nurse mentor. The members are eager to share their experiences as part of the Kavidi Community Adherence Group. Formed in May 2017, the support group brings together people living with HIV who are on antiretroviral therapy (ART) and helps them stay on their treatment regimens, while helping health facilities retain their clients.

The leader is Enata*. “I’m very proud of each member of the group,” she says. “Since the initiation of the group, no member has defaulted from care. The group has bonded and we are accountable to each other for how we take our ART.” Group members help each other adhere to the medication and achieve viral suppression.

Being part of the group also provides support for people with HIV in some not-so-obvious ways. For example, it reduces the transportation costs of going to collect medication. Now, one person goes to the clinic every three months to collect ART for everyone, freeing up time for everyone else to work to support their families.

Membership and participation in the group are very important to Timo (38) and his girlfriend Mariana (29), who are about to become proud parents. In 2014 they both tested HIV-positive and began ART soon after. Mariana struggled to accept her HIV status and to adhere to her antiretroviral therapy.

Today, we are about to have an HIV-negative baby. So all things are possible.

“At first, I was in denial, but with my boyfriend by my side, we managed to support each other,” she says. “When I tested positive, the thought of having children never crossed my mind—all I saw was death. I didn’t think it would be possible to get pregnant, but we listened to the advice we got from the health workers about planning for pregnancy while adhering to treatment and keeping our viral loads suppressed and it made me realize that it was possible. Today, we are about to have an HIV-negative baby. So all things are possible these days.”

Mariana was ashamed of her status for a long time. She alienated everyone around her and it almost cost her her life. At one point, she even stopped taking her medication, which caused her viral load to rise. She said that joining the group made her realize that HIV was not a death sentence. It’s helping her and her boyfriend live healthy lives.

I was determined to stay healthy to become a member.

“To join the group, I had to have a suppressed viral load, which is one of the requirements,” Mariana says. “And because I saw the benefits of the group from my boyfriend who joined the group before me, I was determined to stay healthy to become a member. After taking my HIV medication daily for three months as prescribed, my viral load dropped to an undetectable level. I was so happy.”

Pregnant women are not eligible to remain in Community Adherence Groups because they require frequent check-ups at the health facility, so Mariana will rejoin the group after she gives birth and is cleared by her doctor as stable.

Her partner, Timo, says that although discrimination against people living with HIV is better now than it was in 2014 when he was diagnosed, there are still people who look down on them, even if they are on ART. He also thinks men in particular are still afraid and embarrassed to join the group or even talk about HIV.

“Men are leaders in the community and don’t want to be seen taking ART,” Timo says. “But I encourage other men to not be ashamed of this condition and go for HIV testing so that they know their status—it promotes a healthy lifestyle.”

The Community Adherence Groups have improved patient-centered care and peer support for adherence and viral load monitoring. At the same time, the health system has seen a decongestion of facilities, giving health workers more time to treat unstable patients. Plans are underway to evaluate the impact of these groups on clinical outcomes, including sustained viral load suppression and retention in care.

The Community Adherence Group initiative is spearheaded by the Ministry of Health and Social Services in collaboration with donors that include PEPFAR and USAID. IntraHealth International leads UTAP and has partnered with district health teams to equip frontline health workers and people living with HIV with the necessary capacity to establish, expand, and maintain Community Adherence Groups.

*Names have been changed for anonymity.

By Valery Mwashekele

Former communications officer, IntraHealth International

USAID HIV Clinical Services Technical Assistance Project HIV & AIDS Community Health World AIDS Day Community Health Workers Namibia

HIV meds at a clinic in Omuntele, Namibia. Photo taken by Morgana Wingard for IntraHealth International.

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Twelve Years Later, HIV in Namibia Looks Very Different

mnathe — Tue, 24 Jul 2018 19:48:17 +0000

Twelve Years Later, HIV in Namibia Looks Very Different mnathe July 24, 2018

July 24, 2018

There's been enormous progress here, but adolescent girls and young women still face particular risk.

Last month, I returned to Namibia for the first time in 12 years.

I lived here in 2005-2006 as a technical advisor to a large HIV/AIDS prevention program—a time when the epidemic was raging through Namibian communities. The prevalence rates were mindboggling, 24% in places such as Katima Mulilo. Although treatment was available, the services were not readily available or accessible.

It felt like we couldn’t inform and educate communities quickly enough or train enough health workers to counsel, test, and educate patients to meet the need. Messages were tested and retested to try and reach our target audiences.

I remember driving from town to town in the north and seeing graveyards where the small crosses that marked each grave started at the side of the road and disappeared into the distance.

The graveyards are still here, but they’re not expanding at the rate they were 10 years ago.

Twelve years later, I’ve returned to learn about our USAID Technical Assistance Project (UTAP), which is strengthening organizational and health worker capacity to deliver HIV services, both in the public sector and in facilities operated by nongovernmental organizations. Namibia has achieved enormous success since I was last here. It is hailed as one of the countries close to reaching epidemic control and there is pressure on government and all implementing partners to deliver more and to know the data in such detail that each and every person, their family members, and their sexual networks are tested and referred for treatment or other services, depending on the outcome of their tests.

I am up in the north of the country again for a quarterly review meeting. The graveyards are still here, but they’re not expanding at the rate they were 10 years ago and there’s an upbeat energy. Economically, things are bustling—shops and businesses line the side of roads and traffic like I don’t remember fills the main road that links the northern towns of Oshakati, Ondangwa, and Onandjokwe.

I sit through our team’s meeting and am impressed with the level of discussion and analysis around data, the challenges to reach targets, and the technical approaches the team has tried and tested to find people who live with HIV, start them on antiretroviral therapy (ART), and support their adherence to it.

However, it’s a conversation with the team’s communications manager that really catches my attention.

This is the generation of girls who were born with HIV and have been on treatment all their lives.

She recently traveled to a number of sites around the country to develop a success story on teen clubs that are helping HIV-positive girls adhere to their treatment and cope with adolescent issues that are exacerbated by living with HIV at such a young age.

This is the generation of girls who were born with HIV and have been on treatment all their lives. She tells me heartbreaking stories that she struggled to listen to.

Like the 13-year-old whose classmates found her ART pills in her school bag and tossed them around the classroom, publicly announcing that ‘she has beans’—beans is slang for ART meds. The shame and humiliation brought her to tears.

Or the 16-year-old who is angry at her parents for giving birth to her knowing that they were infected with HIV. The resentment of having to take medication for life. The overall fear, confusion and frustration of wanting a boyfriend and future dreams of marriage and a family. How to disclose her status to her peers without being rejected and treated differently.

I think of my own strong-willed, passionate, and ambitious 16-year-old daughter and what it would be like to tell her that she has HIV and will have to take medication for life without feeling like I’d failed her terribly. The arguments and pleading we’d have for her to take her medication daily. The difficult questions about how to think about her future in a positive light and creating a vision of success. The importance of being a role model of an adult who is living positively and managing the dynamics in a family where all or some members are HIV-positive. The stress of it all in a context of communities that are struggling economically, where violence against women and alcohol abuse are rampant.

It is in this reality that we cannot afford to lose sight of how vulnerable these young women are, and of their emotional and social needs. They continue to be the group most at risk of HIV infection, both through mother-to-child transmission and through older men who have sex with young girls. Through a new five-year award from the US Agency for International Development, we’ll be working together with Project Hope Namibia on the new DREAMS Activity to change this.

We’ve made incredible global progress toward eliminating AIDS as a public health threat. HIV-related deaths are down, and access to treatment is up. But while numbers, targets, and results are important, they cannot take priority over providing comprehensive services for those who need them most, including these adolescent girls in Namibia.

The need for support groups for young girls and parents is critical if countries are to reach epidemic control. The need for life skills, peer support, and understanding cannot be underestimated.

At the International AIDS Conference this week? Stop by booth 220 or come to one of our many sessions to learn more about IntraHealth’s work in Namibia and beyond to end the epidemic.

IntraHealth’s USAID HIV Clinical Services Technical Assistance Project in Namibia is funded by the US Agency for International Development (USAID) through the President’s Emergency Plan for AIDS Response (PEPFAR).

By Kate Stratten

Vice president, programs

USAID HIV Clinical Services Technical Assistance Project HIV & AIDS International AIDS Conference Youth Engagement Namibia

Namibia is close to reaching epidemic control, thanks in part to more widely available antiretroviral medications like these. Photo by Morgana Wingard for IntraHealth International.

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Teen Clubs in Namibia Are Shaping a New Future for Kids with HIV

mnathe — Mon, 16 Apr 2018 14:53:37 +0000

Teen Clubs in Namibia Are Shaping a New Future for Kids with HIV mnathe April 16, 2018

April 16, 2018

For some kids, adolescence began with a diagnosis. These health workers are helping them navigate all that comes with it.

In remote northern Namibia, more than 30 teenagers have gathered at the Andara District Hospital. They’re playing games, socializing, and just being kids.

They’re also sharing their experiences around antiretroviral medications, self-esteem, mental health, teenage pregnancies and abuse, high viral loads, and other issues many HIV-positive teens have on their minds.

There are an estimated 17,000 young people living with HIV in Namibia, including hundreds in Andara district in the Kavango East region. Most of these children have lost one or both of their parents to HIV. Many more are abandoned or shunned.

As I listen to the group, one boy’s comment really sticks with me.

While providing antiretroviral therapy (ART) services to children in Andara, IntraHealth International and local health workers found that HIV-positive adolescents in the district had lower rates of adherence to ART, which was resulting in higher viral loads than in local adults. Health workers also found that adolescents, especially the school-going and orphans of this group, struggled to keep their ART clinic appointments.

This could be because they hadn’t disclosed their HIV status to others. Or it could be because of stigma and discrimination, or the long distance from home or school, or lack of support from guardians.

Whatever the reasons, local health workers wanted to help.

HIV care is more than just ART

That’s why Andara district decided to not only equip health workers with the skills and knowledge they need to provide services specifically to teens, but also to establish teen clubs.

The district, in collaboration with IntraHealth’s USAID HIV Clinical Services Technical Assistance Project and the Ministry of Gender Equality and Child Welfare, conducted a series of trainings to make sure Andara’s health workers were ready to provide the care adolescents need. The primary health care supervisor, nurses, health assistants, and the nurse leading the teen club all attended the trainings, which covered topics such as HIV disclosure for children.

When Andara district and the newly trained health workers introduced the teen clubs in November 2017, attendance was low. But slowly, positive feedback from attendees spread. Now the Andara District Hospital hosts a teen club meeting every month, led by a health professional and a community facilitator, where dozens of kids between the ages of 10 and 19 gather.

As I listen to the group, one boy’s comment really sticks with me. He is 14 years old, and tested positive at 13. He learned about the teen club from an ART nurse at the hospital.

“Before I started coming here, I was hopeless,” he says. “I was afraid of having HIV and of dying. Now I’m more at peace because I know that if I take my medicine, I can live with HIV. I’m not afraid anymore. I’ve learnt that being positive does not mean that I’m an outcast in the community.”

Although he’s struggling with a high viral load right now, he believes that, with the support and information he’s receiving, he will manage to reach such a low viral load that it becomes undetectable.

For many of these children, adolescence began with a diagnosis.

This young boy exemplifies how psychosocial support works in concert with medical care and treatment to give people who live with HIV a new outlook on their future.

“I enjoy working with these teenagers,” says Olivia Simango, a registered nurse, ART in-charge, and teen club leader. “I understand their problems and fears. It is rewarding when you see change in their behavior—like before, most of these kids had poor adherence to treatment and follow-up to appointments, but now the adherence is good and they stick to follow-ups.”

A new journey

For many of these children, the transition to adolescence began with learning that they are HIV-positive. This can be both a mental and physical challenge.

“This is the group in our society for whom it is most difficult to come to terms with their health status,” Simango says. “I enjoy managing to help them through whatever challenges they are faced with, successfully solving problems, achieving the desired results.”

Most of the young people at the club were informed about their status by counselors, health workers, or social workers who are involved in the disclosure process. Once they’ve learned their HIV status, they are eligible to enroll in the teen club and the psychosocial support program. Meeting dates are communicated through SMS text messages and signs posted at the clinic.

Comprehensive HIV care and treatment goes beyond providing antiretroviral medications. This psychosocial support is essential, especially for children and teenagers. A strong social network with positive role models can help them overcome the daily challenges of living with HIV.

The Andara team is hoping the initiative will bridge gaps between parents, their children, and the service providers, and ultimately foster a relationship that will benefit all stakeholders in the fight against HIV and AIDS.

Through this, young people can build positive relationships, improve their self-esteem, and acquire life skills to better manage their health, leading to a life like any other teen.

IntraHealth is working with the government of Namibia to increase the number of health workers providing HIV services and provide the support and training they need to reach the country’s goal of an AIDS-free generation. IntraHealth’s USAID HIV Clinical Services Technical Assistance Project in Namibia is funded by the US Agency for International Development (USAID) through the President’s Emergency Plan for AIDS Response (PEPFAR).

By Valery Mwashekele

Former communications officer, IntraHealth International

USAID HIV Clinical Services Technical Assistance Project HIV & AIDS Community Health Youth Engagement Namibia

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Health Officials Tap into Powerful Data to Expand HIV Services in Namibia

mnathe — Thu, 30 Nov 2017 15:31:47 +0000

Health Officials Tap into Powerful Data to Expand HIV Services in Namibia mnathe November 30, 2017 November 30, 2017

Health officials in Namibia are using data from the first-ever national Workforce Indicators of Staffing Needs (WISN) assessment to expand access to antiretroviral therapy (ART), update national health policies, and inform their budgets as they shape the future of Namibia’s health workforce.

The WISN method, developed by the World Health Organization, assesses workload pressure on health workers—including what kinds of tasks they perform, how long those tasks take, how many times they must perform them throughout the day, and more. Based on those workloads, WISN helps calculate exactly how many health workers of a particular cadre are required in a given health facility.

The data revealed severe staff shortages.

Namibia’s Ministry of Health and Social Services teamed up with IntraHealth International to undertake the assessment on a national scale—including every public health facility—in 2013. The data revealed severe staff shortages, particularly of doctors and pharmacists, and a tendency for nurses to be clustered in hospitals, leaving smaller health centers with too few nurses.

Early in the analysis, it became clear that requiring clients to see a physician for all ART services was creating a major bottleneck that delayed services for many Namibians living with HIV. The number of staff required for these services was generally about a 50/50 distribution of doctors and nurses.

So after analyzing the data and working with IntraHealth’s USAID HIV Clinical Services Technical Assistance Project to demonstrate that nurses could safely and effectively deliver ART services, the ministry changed its policies and procedures. Now, nurses who undergo a new ART certification are authorized to provide ongoing ART services to clients who are already enrolled.

After instituting this new task-sharing practice, the ratio of staff needed for ART services changed to about 80% nurses and 20% doctors. Physicians were freed up to focus on the more complex task of enrolling new clients in ART. This change in skill mix had a significant impact on costs.

After analyzing the data, the ministry changed its policies and procedures.

But the changes didn’t stop there. Using the WISN results, the ministry found that adding ART services to the nurses’ already-full workloads would mean that some of the busiest facilities needed more nurses on staff. As a result, the project has hired 69 additional nurses for the facilities with highest demand to help the ministry achieve epidemic control.

Officials are using WISN results to make other decisions about health policies, health worker training and deployment, and changes within the health system, based on IntraHealth’s recommendations. These include:

Increasing the number of positions for the cadres in shortest supply
Redistributing existing staff to address inequalities
Reviewing health facility classifications
Considering task-sharing based on scope of practice and competency
Creating new cadres or specialized tracks within existing cadres
Introducing competency-based training
Consolidating and improving health information systems

Health and finance officials have found the results to be so valuable when drafting budgets for the health sector for the past three fiscal years that they are now considering a second assessment to update the data. They’ve also used WISN data to inform their restructuring decisions.

Namibia’s government is working to increase the number of trained doctors, pharmacists, and other health workers in the country in part to eventually achieve the UNAIDS 90-90-90 targets for HIV. This would mean that 90% of all people living with HIV know their status; 90% of those diagnosed with HIV receive antiretroviral treatment; and 90% of the people on treatment are living healthy lives with suppressed viral loads. To reach that target, Namibia will have to put an additional 42,000 patients on ART.

IntraHealth International’s USAID HIV Clinical Services Technical Assistance Project is funded by the US Agency for International Development through the President’s Emergency Plan for AIDS Relief (PEPFAR).

Namibia HIV & AIDS Technology Policy & Advocacy World AIDS Day Health Workforce & Systems USAID HIV Clinical Services Technical Assistance Project

Graduates of Leadership Program Help Shape the Future of Health Workforce Development in Namibia

mnathe — Tue, 07 Nov 2017 19:29:39 +0000

Graduates of Leadership Program Help Shape the Future of Health Workforce Development in Namibia mnathe November 07, 2017 November 07, 2017

Fourteen new leaders graduated last month from IntraHealth International’s 2017 leadership development program in Namibia. They include nurses, physicians, information technologists, technical advisors, finance managers, and communications professionals from IntraHealth’s USAID HIV Clinical Services Technical Assistance Project.

The field of health workforce development needs strong leaders who can make tough decisions, navigate complex relationships, and communicate well with anyone. That’s why IntraHealth is investing in a new generation of leaders in countries with the greatest shortage of health workers and the greatest need for a strong health workforce—including Namibia.

The leadership development program’s blended-learning framework enabled participants to learn on the job, increasing their leadership perspectives, knowledge, and skills.

The year-long program, led by senior program manager Nick Ford, was facilitated virtually and has five integrated, key learning components:

self-assessments and reflections
development and execution of customized growth plans
monthly courses and tools
coaching
moderated peer-to-peer sharing

After a year of learning together, on Thursday, October 12, 2017, the leaders received certificates of successful completion from Pape Gaye, president and CEO of IntraHealth, and Maureen Corbett, vice president of programs.

Pamela McQuide, IntraHealth’s country director for Namibia, is very proud of the team.

“I had the opportunity to witness the participants during the sessions and saw how they have advanced their skills in health care operations, strategy, leadership and coaching, and critical thinking,” she says.

You don’t need to have a title to be leader.

“The program helped me a lot to improve my leadership skills,” says Dr. Samson Ndhlovu, HIV clinical mentor and quality of care coordinator. “It helped me to set annual goals and objectives, as well as monitor the progress of these goals. It taught me how to build and lead teams. It also taught me effective communication, effective problem-solving, and decision-making.”

Dr. Pearl Kalimugogo, senior clinical director, says the program made her realize that “you don’t need to have a title to be leader—you can be a leader in your own capacity. My plea is to extend the program to others in the project.”

The deputy chief of party, Simon Mathias, says IntraHealth’s leadership development program helped him to grow as a leader. “The 360-degree assessment that led to the development of my individual development plan has immensely helped me to draw up and follow on an IDP that I am really proud of,” he says, “like enrolling myself in a master’s in public health program that I am still pursuing today.”

The program has been so successful for IntraHealth staff in the US and Namibia that it’s gotten the attention of our government partners. We’re now working with Namibia’s Ministry of Health and Social Services to customize a leadership program for their leaders in Kavango Region in northern Namibia.

IntraHealth’s USAID HIV Clinical Services Technical Assistance Project is funded by the US Agency for International Development through the President’s Emergency Plan for AIDS Relief (PEPFAR).

Valery Mwashekele contributed reporting for this story.

Namibia HIV & AIDS Education & Performance Leadership and GovernanceIntraHealth leaders and participants in the UTAP Leadership Development Program celebrated in Windhoek, Namibia, last month. Back row, from left to right: Pamela McQuide, Pearl Kalimugogo, Ria Bock, Elize Booys, Elsie Hlahla, Rosaline Hendricks, Leilanie Chamberlain, Maureen Corbett, and Trilaine Massey. Front row: Cherizaan Willemse, Maritza Titus, Oretu Kavari, and Valery Mwashekele. Photo by Cherizaan Willemse for IntraHealth International.USAID HIV Clinical Services Technical Assistance Project

Nurses Come Out of Retirement to Fight HIV in Namibia

mnathe — Wed, 02 Aug 2017 19:40:02 +0000

Nurses Come Out of Retirement to Fight HIV in Namibia mnathe August 02, 2017

August 03, 2017

They’re still strong—and ready to help end the country's epidemic.

This aritcle originally appeared in Devex:

Shirley Mwellie was about to get on a plane when she got the letter. It had arrived while she was visiting family in her hometown of Windhoek, Namibia, on leave from her job in England, where she’d been working as a nurse for 14 years. Mwellie is 69, well past the mandatory retirement age of 60 for nurses in Namibia.

The letter caught her eye because it was addressed to Namibian nurses either in retirement or about to retire, who were up for a challenge: Would they like to keep working for another two years and help fill a crucial gap in the country’s health workforce?

“And so,” Shirley said raising her eyebrows with a smile, “I decided to stay. It’s good to be amongst your own people, saving your own people,” she says. “You know their difficulties. You know what they are striving for.”

Like many countries, Namibia has a shortage of health workers.

Namibia was one of the hardest-hit countries during the height of the HIV epidemic, when some 22% of the adult population there was infected. HIV prevalence remains high today at 13.3%, according to the Ministry of Health and Social Services.

Like many countries in the region, Namibia has a shortage of health workers. Until the past decade or so, it has relied on immigrants from other African countries to fill the gaps, while many of Namibia’s few homegrown nurses left for higher-paying opportunities in private hospitals or abroad.

Then in 2013, Namibia became the first country to conduct a national assessment using the World Health Organization tool, Workload Indicators of Staffing Needs. As a result, the government now has hard data on exactly how many health workers its people need in each health facility, as well as which types are most in demand, and where.

Solving the shortage won’t happen overnight. To speed up the process, Namibia’s Ministry of Health and Social Services and the U.S. Agency for International Development teamed up to recruit much-needed HIV nurses from an unlikely candidate pool: Retirees.

An unconventional idea

The idea emerged when the ministry asked IntraHealth International’s USAID Technical Assistance Project to help it recruit 80 additional nurses and deploy them to the areas with the greatest HIV prevalence and highest unmet need for antiretroviral therapy, or ART, mostly in the country’s north.

IntraHealth agreed to help. “Then I thought to myself, ‘Where am I going to find these nurses?,’” recalls Pamela McQuide, IntraHealth’s country director in Namibia and a nurse by training. Local health professional schools are training new cohorts of in-demand health workers, she says, but they’re not in the workforce yet.

The mandatory age of retirement for nurses in Namibia is relatively low. Regardless of whether a nurse is still healthy and willing to work—which is more and more often the case—those in the public sector must retire from the workforce when they reach 60.

This gave McQuide an idea.

"We don't want to sit. We want to do."

IntraHealth put out adverts calling on retired nurses from around the country, asking if any would be willing to come back to work for two years, which is the duration of the project—buying time for more newly trained health workers to graduate. The influx of workers would also inject experience into the country’s work to achieve the UNAIDS 90-90-90 targets for HIV. To reach that target, Namibia will have to put an additional 42,000 patients on ART.

Forty nurses, including Mwellie, answered the call.

“We don’t want to sit,” Mwellie says from her new station at the Omuthiya District Hospital's HIV clinic in northern Namibia. “We want to do.”

A new dynamic

A whole new health care dynamic is cropping up in facilities where the unretired recruits are stationed. More Namibians have access to HIV care closer to their homes.

Many of the older nurses, particularly those trained on HIV services, take a holistic approach to care. Mwellie and her colleagues tend to go off-script during client interactions—“How are you feeling about things today?” they might ask.

Many clients are unused to this. Understaffed facilities and heavy client loads sometimes make that level of interaction impossible. Having more hands on deck—particularly hands that have a lifetime of experience—can help make it possible.

A client named Johnas Nstor was recently visiting Omuthiya and talking with Olivia Nandy, 68, another nurse hired by the project. He was nervous about the visit and fidgeting, but Nandy spoke kindly as she explained the medications he needed.

“You are very good people,” he told her at the end of his visit. “I thought maybe you would shout at me because I wasn’t taking my medication. But you are good people.”

The older nurses share their expertise with their younger colleagues. The younger health workers have things to teach them, too.

“It can be a challenge with the ART care,” says nurse Ruusa Shipena, ART supervisor at Shanamutango Clinic at Onandjokwe Hospital, who oversees several of the unretired nurses in their work. “Most of the retired nurses have never worked with HIV care in the past, so they must get used to this concept. Some learn fast, but we have to be patient, because it’s all new to them.”

Find creative ways to put experience to work.

In her work, Mwellie has seen trouble beyond just HIV. Substance abuse in northern Namibia is a huge problem, she says, and there are very few services for the elderly. As Namibians live longer—particularly those who live with HIV—they will need more complex care that doesn’t exist.

When she “re-retires,” Mwellie says, maybe she’ll open a clinic to fill that gap.

Recommendations

McQuide and her team have three recommendations for other countries working to creatively build fit-for-purpose health workforces in the midst of health worker shortages.

They have learned to first review policy, which may be unintentionally holding the health workforce back. In Namibia, the mandatory retirement age may be keeping plenty of nurses who are eager to keep working out of the workforce, even as the country desperately needs them.

Interventions should also look locally first. Homegrown health workers are crucial to maintaining trust within their communities and are the most sustainable solution to the shortage.

Finally, find creative ways to put experience to work. In Namibia, the team has found that many clients immediately trust and respect older nurses, whose age and experience are unparalleled assets when it comes to HIV care—and health services of all kinds.

IntraHealth International’s USAID HIV Clinical Services Technical Assistance Project is funded by the US Agency for International Development through the President’s Emergency Plan for AIDS Relief (PEPFAR).

Valery Mwashekele and Cherizaan Willemse contributed reporting to this story.

By Margarite Nathe

Strategic communications advisor, IntraHealth International

USAID HIV Clinical Services Technical Assistance Project HIV & AIDS Policy & Advocacy Health Workforce & Systems Nurses Namibia

Photos

A much-needed benefit of the recruitment initiative is that older nurses have plenty to teach younger health workers in the facilities where they’re stationed, and vice versa. Here, Shirley Mwellie, 69 (center) talks with pharmacist assistant Elina Nantinda, 25 (right), at Omuthiya District Hospital. Photo by Morgana Wingard for IntraHealth International.

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Infant HIV Testing Soars from 30% to 94% in Northern Namibian District

mnathe — Wed, 07 Jun 2017 16:15:53 +0000

Infant HIV Testing Soars from 30% to 94% in Northern Namibian District mnathe June 07, 2017 June 07, 2017

The number of infants tested for HIV in the northern Namibian district of Nyangana skyrocketed over the past year—from 29.3% to 94.4%—thanks in part to a new tracking system developed by IntraHealth International.

IntraHealth nurse mentor Rightwell Zulu and district monitoring and evaluation officer Felistas Shindimba were part of the team of health workers at Nyangana District Hospital who developed the system to test nearly every baby born to HIV-positive mothers in the district. Their goal is to prevent HIV transmission in all babies in the district, and to start HIV-positive babies on treatment as soon as possible.

Today, according to the Ministry of Health and Social Services, overall HIV prevalence in Namibia is 17.2%, and highest in the northern regions. Nyangana District Hospital provides basic health services to over 38,000 Namibians in Kavango East, the region with the third-highest HIV prevalence rate in the country.

Early infant diagnosis is crucial, as HIV-positive babies face the highest risk of death within their first three months of life.

But health workers and policy-makers in Namibia have made great progress in reducing mother-to-child HIV transmission. In fact, the number of children born HIV-positive has dropped by more than 90% since 2004, said US Ambassador Thomas Daughton at an event celebrating this most recent milestone at Nyangana District Hospital.

“However,” Ambassador Daughton said, “there is no reason to relax our efforts or believe we have beaten the disease yet.”

The system Zulu and his team developed involves a detailed procedure that tracks HIV-positive mothers and ensures their babies are tested at six weeks, nine months, and 18 months after birth. This time period is critical, as infants can contract the virus through breastmilk if the mother is not taking antiretroviral medication consistently.

Before each time interval, the team calls each mother to confirm her appointment. If a client does not show up for a scheduled appointment, Shindimba picks up the phone. If that does not work, she coordinates with community health workers who then visit the mother’s village or home to ensure she and her infant get the care they need.

The system requires close coordination among the hospital’s nurses and health assistants, outreach clinic staff, and community health workers, who all work together to keep client data up to date and complete. Eventually, the team says, it will reach 100% of babies born to HIV-positive mothers, and reach their goal of zero HIV infections among babies in the region.

“Innovative platforms such as the one designed by IntraHealth, tailored to decentralized health settings, make it easy for health workers to carry out tests and follow up on babies without requiring mothers to travel long distances to the nearest hospital,” Daughton said this month. “Their tracking system is a huge success, making sure mothers and their babies remain in the system.”

IntraHealth is working with the government of Namibia to increase the number of health workers providing HIV services and provide the support and training they need to reach the country’s goal of an AIDS-free generation. IntraHealth’s USAID HIV Clinical Services Technical Assistance Project in Namibia is funded by the US Agency for International Development through the President’s Emergency Plan for AIDS Response (PEPFAR). Read more about IntraHealth’s work in Namibia.

Namibia HIV & AIDS Maternal and Newborn Health Measurement & Analytics Measurement and Evaluation Community Health Workers NursesA health worker tests an infant for HIV in northern Namibia. Photo by Trevor Snapp for IntraHealth International.USAID HIV Clinical Services Technical Assistance Project

Keeping Babies HIV-Free

mnathe — Fri, 26 May 2017 20:38:48 +0000

Keeping Babies HIV-Free mnathe May 26, 2017

May 26, 2017

This team of health workers in northern Namibia is determined to test 100% of babies born to HIV-positive mothers. And they're almost there.

Squinting in the hot northern Namibian sun, a man smartly dressed in a nurse’s uniform greets us with a warm smile. Rightwell Zulu, or “Dr. Zulu,” as he is affectionately called by his colleagues, is a nurse mentor at Nyangana District Hospital in Namibia.

Zulu, together with his colleagues, Veronika Shivute and Felistas Shindimba, developed a system that has helped this hospital test nearly every baby born there to HIV-positive mothers. Their work is supported by IntraHealth International and USAID/Namibia through the U.S. President’s Emergency Plan for AIDS Relief.

Early infant diagnosis is critical.

In Namibia, HIV prevalence is highest in the northern regions, including Kavango East, which has the third-highest HIV prevalence rate in the country. The Nyangana District Hospital provides basic health services to over 38,000 Namibians in Kavango East, including HIV testing, counseling and treatment. The hospital is known for its busy maternity ward, and is the sole facility in Nyangana equipped to carry out deliveries.

An important goal for hospital staff is to determine how many HIV-exposed babies are in the district and how many of them are being tested. A baby can contract HIV while a mother is still pregnant, or after birth through breastfeeding, making early infant diagnosis critical.

Zulu and his team developed a detailed procedure that ensures close coordination among the hospital’s nurses and health assistants, outreach clinic staff and community health workers. The system tracks HIV-positive mothers and ensures their babies are tested at six weeks, nine months and 18 months. As a reminder, prior to each time interval, the team calls each mother, confirming the appointment.

Zulu and his team aim to start HIV-positive babies on treatment as soon as possible, and keep HIV-negative babies HIV-free.

Shindimba, who is the district’s monitoring and evaluation officer, makes monthly visits to outreach clinics.

“Sometimes you see that mothers are missing,” Shindimba says. “For example, we might have referred a mother to a certain clinic for her first baby follow-up on December 6. When we go at the end of December to check the appointment registers, we might see that the mother did not come on her assigned day to that clinic.”

When this happens, Shindimba calls the mother. In cases where mothers cannot be reached by phone, she shares the list with community health workers. They are in charge of connecting with mothers at their homes or in their villages, and coordinating with outreach clinics to ensure mothers reschedule their baby’s follow-up visit for HIV testing. Shindimba also uses the monthly visits to collect data on HIV-exposed infants.

Zulu and his team increased rates of early infant testing from 29.3% to 94.4% in Nyangana.

At first, there were many gaps in data. However, by improving regular communication with mothers, outreach clinic staff and community health workers, Zulu and Shindimba feel that data quality has greatly improved, and they are able to adequately trace HIV-exposed infants in Nyangana.

Within the last year, three babies in the Nyangana district were born HIV-positive, all of whom are currently on treatment. Between the start of the tracking system in October 2015 and June 2016, Zulu and his team increased rates of early infant testing from 29.3% to 94.4% of all the babies born in Nyangana to HIV-positive mothers. That’s nearly 100 percent—a goal the team believes it will eventually reach.

Their patients are taking note.

“With support, encouragement and health education, I’m reminded to take my baby for the required HIV test and administration of HIV medications to prevent my baby being infected since I am a HIV-positive mother. I learned that it’s possible to be HIV-positive and have a HIV-negative child,” says Kamonga Eveline, one mother who has benefited from the improved early infant diagnosis system.

Mashika Elizabeth, another mother, shares that improved communication with the hospital and clinic staff serves as a reminder and encouragement to take her baby for HIV tests on time and breastfeed while taking antiretroviral medications.

“I take my medication on time every day to ensure my baby does not get infected. I believe this is the benefit for the nation because it prevents new infections from mothers to babies,” she told us.

Innocent children are still getting HIV.

While their system has been largely successful, some challenges still exist. Phone numbers change or become unreachable. Mothers transfer to different clinics without notification. Regardless of the challenges, Zulu and his team continue to work hard to improve their tracking system.

“This project is my baby, and we still want to see how we can improve this system,” Zulu says. “The issue for me now is that innocent children are still getting HIV. This is what I care about. When you see a child who tests positive, then we pause. The programs are there, but something is still not working.”

Valery Mwashekele and Cherizaan Willemse of IntraHealth International contributed to this story.

This post was originally published in the May/June 2017 issue of USAID's Frontlines.

By Sheena Sharifi Abadan

HIV communications advisor, USAID/Namibia

USAID HIV Clinical Services Technical Assistance Project HIV & AIDS Maternal and Newborn Health Nurses Namibia

Photos

From left to right: Veronika Shivute, Rightwell Zulu, and Felistas Shindimba work together to improve early HIV diagnosis for infants so those who test positive can start treatment as soon as possible and those who test negative can stay HIV-free. Photo courtesy of Sheena Sharifi, USAID

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Through the Pharmacy Window

mnathe — Fri, 19 May 2017 15:22:08 +0000

Through the Pharmacy Window mnathe May 19, 2017

May 19, 2017

Meet Elina Nantinda, one of a new generation of health workers who are turning the tide of Namibia’s HIV epidemic.

“When I was in grade 8, I was into two things: fashion and medicine,” says Elina Nantinda, a 25-year-old pharmacy assistant in rural Namibia. “So I decided to study hard. I thought, ‘It would be so nice to work with medicine and to know more about yourself and how medicine works in your body.’”

Today she runs the pharmacy at Omuthiya District Hospital’s HIV clinic in northern Namibia, dispensing antiretroviral medicines to a hundred clients per day, on average. People come from miles around—most on foot—for HIV services at Omuthiya. And most come to see Elina at some point.

Being alone, you learn more and faster.

When she started this job at Omuthiya last year, Elina spent two days working with a senior pharmacist. But then that person was moved to the main clinic, and she’s been on her own ever since.

“Being alone, you learn more and faster,” Elina says. “But we need another person in our pharmacy, so that when one is dispensing the medications, the other is entering data into the computer.”

Like all the other health workers at Omuthiya, Elina is constantly busy. Yet she’s always on the watch for clients who look lost or in need of help, and her watchfulness helps the whole clinic run more smoothly.

“I watch their facial expressions,” Elina says, particularly those of clients who come to pick up their medications—and especially when they don’t ask questions. “If they look confused or uncertain, I know I have to find a way for them to understand. I know any error on their part is going to be my fault. And sometimes patients don’t want to hear instructions about their medications because they think they’ve been taking them so long, they already know everything.”

In fact, HIV has become a way of life for many in Namibia. Today, according to the Ministry of Health and Social Services, overall HIV prevalence in the country is 17.2%, and slightly higher in Omuthiya.

So Elina asks them, quietly and kindly, to describe to her how they take their meds. This is how she sometimes finds out a client may be taking too many pills at once.

“This is really bad,” she says. “They have heart pains and they don’t sleep, so they usually come back to us within days.”

Or she sometimes finds that clients are taking the pills at the wrong time.

I worried that God would feel bad about me if I’m not doing something to help.

“Today a patient came from Onyaanya,” Elina says, which is 39 kilometers away from Omuthiya. “I could see the patient didn’t look normal. I asked, ‘How do you feel?’ The patient told me, ‘Sometimes after I take my medication, I feel like I’m drunk after two hours, and I want to sleep. I just feel like I’m not normal. It’s not me.’ So I asked, ‘How are you taking this medication?’ I found the patient was taking a tablet in the morning”—which is contrary to current guidance.

So Elina explained that the client should start taking the medication at night before going to bed.

Hard-working lady

I ask Elina why she chose medicine over fashion.

“I’ve always been a hard-working lady,” she tells me. “I used to visit the orphans in Windhoek, and I wanted to help them. I worried that God would feel bad about me if I’m not doing something to help.”

She hopes to become a full-fledged pharmacist someday, but will have to raise money for school.

Then I ask Elina if there are any other health workers in her family. She tells me no, she is the only one. So when any of her relatives is feeling bad, they always come to her.

“I feel so proud about that,” she says.

Elina Nantinda is employed through IntraHealth International’s USAID HIV Clinical Services Technical Assistance Project in Namibia, which is funded by the US Agency for International Development through the President’s Emergency Plan for AIDS Relief (PEPFAR). IntraHealth is working with the government of Namibia to increase the number of health workers providing HIV services and provide the support and training they need to reach the country’s goal of an AIDS-free generation. Read more about IntraHealth’s work in Namibia.

Valery Mwashekele and Cherizaan Willemse contributed reporting to this story.

This post originally appeared on the Frontline Health Workers Coalition blog.

By Margarite Nathe

Strategic communications advisor, IntraHealth International

USAID HIV Clinical Services Technical Assistance Project HIV & AIDS Pharmacists Namibia

Photos

Elina Nantinda runs the pharmacy at Omuthiya District Hospital’s HIV clinic in northern Namibia. Photo by Morgana Wingard for IntraHealth International.

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