Analytical summary - HIV/AIDS
Over the past 20 years the HIV epidemic in Namibia has negatively impacted on health and development indicators, and will remain a major challenge for the next 10 to 20 years. Although the number of new HIV infections (incidence) has begun to decline, HIV prevalence in Namibia has stabilised at a high level and continues to burden the health care system, to fuel new infections and to pose serious developmental challenges.
The epidemic impacts both directly and indirectly on the well-being of the vast majority of the population, the performance of the formal and informal economy, the capacity of public and private sectors to provide services, and the attainment of all MDGs (Millennium Development Goals). The primary responsibility for facing the challenges of HIV and AIDS in Namibia lies with the Directorate of Special Programmes of the Ministry of Health and Social Services, working in co-operation with other ministries and initiatives.
With an adult HIV prevalence of approximately 18.8% in 2010, Namibia is ranked among the 10 countries with the highest prevalence levels in the world. An estimated 178,000 people are living with HIV in Namibia, among which some 14,000 children below the age of 15. (MoHSS, 2008) Annual incidence levels are estimated at 5,800 and approximately one quarter of these are due to mother-to-child transmission.
Although during the last few years prevalence rates have decreased by almost 50 percent among young pregnant women aged 15-19, from 12% in 2000 to 6.6% in 2010, the distribution of new infections shows the continued vulnerability of young girls. An estimated 73% of new infections in the age group 15-19 years are among young girls and only 27% in boys. In the age group 20-24 year olds, girls account for 62% of new infections. (MoHSS, 2010)
Providing universal access to HIV prevention, treatment, care and support services has been a development priority for the Namibian government for the past ten years. In 2006 their Third National Development Plan (NDP3) recognized HIV/AIDS as a national development priority and in 2007 a comprehensive National AIDS Policy with a strong human rights basis was adopted by parliament. (Republic of Namibia, 2007)
The country has shown that achieving a massive scale-up of HIV services in a short period of time is feasible, given sufficient political commitment, social mobilisation, financial investment, and close collaboration with both civil society and development partners. The next step for Namibia is to build on the current progress and further scale up its response through evidence-informed and cost-effective interventions. The country will have to manage the transition from an emergency response to a systems strengthening approach so as to achieve long-term sustainability. (MoHSS and UNAIDS, 2011)
The National Strategic Framework for HIV and AIDS 2010/11–2015/16 (NSF) outlines Namibia’s response to HIV and AIDS, providing strategic policy, planning and implementation guidance. The main priority of the NSF is ‘to maintain and improve the quality of life of Namibia’s people by preventing new infections from occurring and by providing comprehensive and quality treatment, care and support for those already infected by HIV and AIDS’. (Republic of Nambia, 2010) It also seeks to reduce the socio-economic impacts of HIV, especially among vulnerable households.
The new NSF also outlines the multi-sectoral coordination framework for enhancing decision making, national ownership and mutual accountability among all stakeholders involved in the national AIDS response. One of Namibia’s four primary health objectives is health system strengthening: ensuring that the health system is able to provide equitable, affordable and high quality services, particularly to disadvantaged and marginalized populations of the country.
ART services have been scaled up rapidly in Namibia, with highly successful results. More than 75,000 people were on ART in March 2010 (MoHSS and UNAIDS, 2011), and nearly 50,000 people were on pre-ART. This roll-out of ART has achieved large reductions in hospital admissions due to HIV-related diseases and in death rates among people living with HIV. Hospitalisation rates decreased from 9,465 in 2006 to 1,597 in 2009, while the number of deaths declined from 2,622 to 359. (MoHSS, 2010)
In 2006, WHO recommended that all patients start ART when their CD4 count falls to 200 or lower, at which point they typically show symptoms of HIV WHO now recommends that ART be initiated as soon as the CD4 count falls to 350 for all HIV-infected patients, regardless of symptoms. (UNAIDS, 2010)
In the area of prevention of mother-to-child transmission (PMTCT), Namibia has made marked progress. Since the start of PMTCT in 2002, the programme has been expanded, and by April 2010 had achieved 77% coverage, with a complete course of ARV for women in need of PMTCT.
However, according to the 2009 Namibia Health Facility Census, only half of the facilities offering PMTCT services provided the complete package of HIV-testing, ARV prophylaxis, counselling for nutrition and infant feeding, as well as family planning counselling services. (MoHSS and ICF Macro, 2011) Further steps that need to be taken to achieve the goal of eliminating MTCT (eMTCT plan) by 2015 are to ensure nationwide coverage of high quality services, to ensure sufficient mother and child care and HIV-related medical services and to achieve prevention of HIV infections among women and of unwanted pregnancies among already HIV-infected women. (The Global Fund, 2011)
Namibia’s impressive scale-up of treatment has been achieved with the help of substantial resources from international partners such as the Global Fund and PEPFAR; while such support has helped the country significantly to reach this position, it does raise questions regarding the sustainability of the response in view of declining donor funding. (MoHSS and UNAIDS, 2011)
For people living with HIV, TB is the most life-threatening opportunistic disease, even for those on ARV therapy; and it is the most common cause of death among people infected with HIV. The joint management of TB and HIV is therefore an important component of the Treatment, Care and Support strategy. (WHO, 2007) Provider-initiated HIV counselling and testing for TB patients is an important element of the TB/HIV collaboration and has led to an increase in the number of people diagnosed with TB being tested for HIV, from only 34% of TB patients in 2006/07 to 74% by March 2010.
Between 2006 and 2009, approximately 60% of TB patients tested for HIV were found to be HIV positive. The TB treatment success rate among HIV infected people has increased from 70% in 2004 to 82% in 2008. (MoHSS and UNAIDS, 2011)
HIV counselling and testing is the backbone of HIV prevention and care interventions, including PMTCT and treatment of HIV. Testing coverage has generally outperformed the targets. In 2009/10 the target was 150,000 while actually 214,581 clients were tested and received results. This includes more than 82,000 who were tested during the national testing day. About 69% of those tested in 2009/10 were females; this is partly explained by the routine HIV testing during antenatal care. Counselling and testing of couples is still low and greater advocacy for this is required. (MoHSS and UNAIDS, 2011)
Safety of healthcare workers working with HIV testing or injecting medications is of utmost importance; all are trained to practise hand hygiene, to take safety precautions when using and disposing of needles, and to report needlestick injuries promptly in order to obtain post-exposure prophylaxis within 72 hours. At the same time efforts are being made to reduce the use of injections to administer medications. (MoHSS, 2010)
The safety of blood supply is assured by the Namibian Blood Transfusion Service (NABTS), an NGO to which the responsibility for implementing the Namibian Blood Policy has been delegated. (MoHSS, 2007) They collect more than 20,000 units of safe blood and blood products annually. Strict procedures are in place to ensure that donors are committed to acting responsibly when donating blood, and each unit of blood taken is subjected to rigorous testing and processing procedures. (WHO Namibia, 2010).
Preventing infections, especially among young people is critical to addressing the HIV epidemic. By 2009, 75% of primary schools and 86% of secondary schools taught life skills, using programmes such as Window of Hope for grades 4-7 and My Future is My Choice for secondary school learners. These are used in addition to other programmes run by civil society partners; they are not yet integrated into the school curriculum, so are not required subjects and thus lack the rigour and commitment needed for optimum effectiveness. Such programmes providing life skills, sexuality education and HIV prevention services should enable young people to protect themselves from being infected by HIV. (MoHSS and UNAIDS, 2011)
The care of orphans and other vulnerable children affected by HIV is a portfolio of the Ministry of Gender Equality, whose plan of action focuses on five areas: rights and protection, education (providing opportunities equal to those for unaffected children), care and support (basic needs for adult care and supervision), health and nutrition, and management and networking (co-ordinating the work of various initiatives and sectors for best outcomes). (MGECW, 2007)
The most recent statistics for the incidence and prevalence of HIV in Namibia comes from the 2010 sentinel survey which gathered information from women attending antenatal clinics from 1992 to 2010. More information is needed about prevalence in men and children, and in other age groups of women, and information is also needed about behaviour patterns relating to HIV incidence. (MoHSS, 2010)
Recent scientific evidence has demonstrated the effectiveness of medical male circumcision, ARV ‘treatment for prevention’ (MoHSS, 2009) and pre-exposure prophylaxis as HIV prevention interventions. Rapid scale-up of such newly available and evidence-based HIV prevention services will be important as part of the combination prevention strategy of the NSF. Efforts and funding expended in finding and providing effective preventive measures will be offset by the savings in treatment costs.
The Global Fund, 2011) As stated in the National AIDS Policy, “the national response must continuously be able to respond to the changing nature of the epidemic, its impacts, and the latest research, information and developments”. (Republic of Namibia, 2007)