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MDG Goal 6: Combat HIV/AIDS, TB, malaria and other diseases

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MDG 6: Status at a Glance
GOALS AND INDICATORS BASELINE STATUS TARGET (2015) TARGET/ GOAL ACHIEVABLE?
MDG 6: COMBAT HIV AND AIDS, MALARIA AND OTHER DISEASES
HIV and AIDS
HIV prevalence among population aged 15-24 Years (%)
8.2% (2006)[1]
8.9% (2012)[1]
5%
Not on target
Condom use at last high-risk sex for 15-49 years age group
Women (%)
-
62.1% (2006/07)[2]
85%
Lack of data
Men (%)
-
78.4% (2006)[2]
90%
Lack of data
Alternative indicator Condom use with non-cohabiting partner (15-49 years)
Women (%)
51% (2000)[3]
62.1% (2006/07)[2]
n/a
No target set
Men (%)
66% (2000)[3]
78.4 (2006/07)[2]
n/a
No target set
Proportion of population aged 15-24 years with comprehensive, correct knowledge of HIV and AIDS
Women (%)
38.9% (2000)[3]
64.9% (2006)[2]
90%
On target
Men (%)
50.7% (2000)[3]
61.9% (2006)[2]
90%
Not on target
Ratio of school attendance of orphans to school attendance of non-orphans aged 10-14 years
0.92(2000)3[3]
1.02 (2006)[2]
1.0
Achieved
Proportion of population (adults and children) with advanced HIV infection with access to ARV drugs (%)
Adults (%)
56% (2006/07) [2]
81.5% (2011)[4]
100%
100% On target
Children (%)
88% (2006/07) 2[2]
83.9% (2011)4[4]
95%
Not on target


Current Status and Trends

Namibia has a mature, generalised HIV epidemic with a high adult (15-49) HIV prevalence[5] of 13.4 percent in 2012 (MOHSS, 2012d:33). Similarly to some other African countries, Namibia experienced a rapid increase in HIV prevalence following the first reported infection in 1986. Adult prevalence reached its peak in 2002 (close to 16 percent) and plateaued at around 13 percent by 2012. The first indicator under MDG 6 is to have halted by 2015 and begun to reverse the spread of HIV and AIDS. Although good progress has been made in the reduction of new HIV infections (incidence), reduction of the prevalence among 15 to 24 year olds to 5 percent is not on target. Prevalence in this age group reached its peak at 17.9 percent in 2002 and declined by 50 percentage points in the following ten years to the current (2012) 8.9 percent (MOHSS, 2012c)[6]. The graph below shows that the prevalence among 15 to 24 year olds consistently decreased from 17.9 percent in 2002 to 14.2 percent in 2006, 10.3 percent in 2010 and 8.9 percent in 2012 (MOHSS, 2012c).

Adult HIV Prevalence 1992-2012.JPG HIV prevalence among population 15-24 years 1990-2015 Actual and Desired Trends.JPG

Although the prevalence among 15 to 24 year olds seems relatively low in 2012, considerable variations were reported across sentinel survey sites. In 2008, Katima Mulilo had the highest prevalence for this age group at 24.1 percent, followed by Tsandi (23.7 percent), Okahao (18.5 percent) and Walvis Bay (15.4 percent). In 2008, the site with the lowest reported prevalence for this age group was at Windhoek Central Hospital (1.4 percent), followed by Opuwo, (4.6 percent), Tsumeb (5.2 percent) and Khorixas (5.5 percent). In 2012, Katima Mulilo still reported the highest HIV prevalence (21.5 percent) among pregnant women between the ages of 15 and 24, followed by Rundu (17.4 percent), Luderitz (14 percent) and Oshikuku (12.2 percent). Windhoek Central Hospital continued to have the lowest prevalence at 0.0 percent in 2012, followed by Karasurg (1.2 percent), Nankudu (1.7 percent) and Usakos (3.3 percent). It is worth noting that prevalence, among pregnant women who participated in HIV sentinel surveys, increased significantly in areas such as Luderitz from 4 percent two years ago to 14.1 percent in 2012. The sentinel survey in 2012 found that in 22 out of 35 sites more than one quarter of the women tested HIV positive. It further reported that “among women for all ages (15 -49 years), from 2010 to 2012 a decline in HIV prevalence rate was observed at 10 (54%) out of 35 sites and an increase was observed at 14 (40%) out of 35 sites. No change was observed at 2 (6%) sites” (MOHSS, 2012c:23).

Variations were reported between age cohorts, with prevalence decreasing for some and increasing for others. The graph below shows that the highest observed prevalence, based on sentinel surveys, was among the 35 to 39 year olds and 30 to 34 year olds, at 33.9 percent and 30.8 percent respectively. The lowest prevalence was found among the 15 to 19 year olds (5.4 percent) followed by 20 to 24 year olds (10.9 percent). Trends show that prevalence continues to rise for the older age groups 30+, while it seems to be declining for the younger age groups, and stabilising for 25 to 49 year olds. Increased prevalence among older age groups is expected, because people on ART are healthier and live longer, while new infections enter the pool of those already infected.

HIV prevalence by age group and year of survey 1994-2012.JPG

New infections continue to decline to 22 infections per day, totalling 8 177 infections in 2011/12. This is a significant achievement. Current trends in new infections show that Namibia is very likely to achieve the NSF target of reducing new infections by 50 percent by 2015/16. Five percent of new infections are estimated to be among children under the age of 15. Two thirds (67 percent) of the new infections among 15 to 24 year olds are among women (MOHSS, 2013a). Comprehensive, correct knowledge of HIV is essential for prevention. Comprehensive knowledge includes knowledge about incorrect beliefs and misconceptions about HIV transmission. The 2015 MDG target was for 90 percent of women and men to have comprehensive knowledge of HIV. With only two data sources, NDHS 2000 and 2006/07, it was difficult to determine trends. The 2011/12 NDHS will provide more accurate and relevant data. However, based on the two available sources, women are on target while men are not on target in relation to having comprehensive knowledge of HIV. There seems to be no significant variation in age in women and men’s knowledge, although those with higher education, in the highest wealth quintiles and living in urban areas had more comprehensive knowledge. Among regions, women in Caprivi and Kunene and men in Ohangwena were subject to the most misconceptions about HIV transmission.

Condom use at last high-risk sexual encounter for 15 to 49 year olds was higher for men than for women across all age groups. The MDG target for 2015 is to achieve 85 percent condom use by women and 90 percent by men. Current trends show that condom use among women is not on target to be achieved, while condom use amongst men is on target. It should be noted that, in 2006/07, 3 percent of women and 16 percent of men reported having had two or more partners in the previous 12 months; while 49 percent of women and 60 percent of men had had higher-risk sexual intercourse over the same period (MOHSS, 2008). Women and men who are not married or cohabitating and those in younger age groups were more likely to engage in high-risk sexual relations and 15 to 19 year old men and women were more likely to engage in high-risk sexual activities than any other age group. Condoms are most likely to be used by younger people and those outside marriage or cohabitation. Three in four men and one in three women in 2006/07 reported having used a condom at last higher-risk intercourse. Women (31 percent) and men (42 percent) in Kavango were the least likely to have used a condom at last high-risk sexual encounter, while women (73 percent) in Khomas and men (84 percent) in Oshana were the most likely (MOHSS, 2008:206-208).

Condom use at last high-risk sex-men proportion 1990-2015 Actual and Desired Trends.JPG


Percentage who reported using a condom consistently with the last higher-risk partner by age.JPG


Proportion of population with advanced HIV infection with access to antiretroviral drugs 1990-2015 Actual and Desired Trends.JPG


The MDG target for ART provision is similar to that of the National Strategic Framework for HIV and AIDS 2010/11 – 2015/16 (NSF). Namibia strives to achieve 100 percent access to ARV drugs for adults with advanced HIV infection and 95 percent for children. The provision of free ART was initiated in 2002 in reaction to alarmingly high AIDS related morbidity and mortality. Significant progress has been made, with an initial coverage of 3 percent in 2003, rising to 53 percent in 2007 and 90 percent in 2010 (MOHSS, 2010g:16). In 2011, 83.9 percent of children between birth and 14 years of age and 81.5 percent of adults with advanced HIV were on ART. Overall, 81.7 percent of HIV positive people were still on treatment 12 months after treatment initiation. With the adoption of the WHO criteria for ART, which saw the CD4 count level for initiation of treatment raised from 200 to 350 in 2010, the number of people on ART will continue to increase. Based on past trends, Namibia is on target to achieve access to ART for adults, but not on track to achieve access to ART for children. The MOHSS (MOHSS, 2012a:69) notes that the number of people on ART increased by 16 453 between April 2010 and March 2011 compared to 11 044 between April 2009 and March 2010. “Of those on ART, 59% were female adults, 31% were male adults, 4% were male children aged 5-14 and 4% were female children aged 5-14 while 1% were male children under 5 years and another 1% were female children under 5 years” (MOHSS, 2012a:72).

Percentage of patients by age category and sex on ART in public facilities.JPG

The MDG goal was to achieve a ratio of 1 for school attendance of orphans and non-orphans aged 10 to 14 years old. Namibia has already achieved this goal by increasing the ratio from 0.92 in the year 2000 to 1.02 in 2006. There is no variation in school attendance between OVC and non-OVC.

Milestones

The overall national HIV and AIDS response in Namibia is guided by the respective short and medium term Five Year Plans, the National Strategic Framework on HIV and AIDS and the National Policy on HIV and AIDS. The policy and the plans are based on Namibia’s commitment towards the wellbeing of all people, as enshrined in the Namibia Constitution. To respond to the overwhelming challenges posed by HIV, Namibia established the National AIDS Control Programme (NACOP) immediately after Independence in 1990. Over the years, Namibia has learned that HIV is not only a health challenge but a developmental challenge across different sectors, giving rise to the National AIDS Coordinating Programme in 1999. A high level HIV and AIDS Committee, chaired by the Minister of MOHSS and co-chaired by the Minister of then Ministry of Regional Local Government and Housing, signified the urgency attached to responding to the epidemic. The commitment of government was stated in a speech by the Prime Minister of Namibia in 2000 when he said, “…the battle against AIDS is a shared responsibility for all Namibians and all people must take responsibility for orphan children to ensure that the disease that kills their parents does not continue to lay waste to their future” (New Era, 2000). Ten years later, the President of Namibia, H. E. President Pohamba at the UN MDG Summit in New York in September 2010 made a commitment to ensuring that in Namibia no child will be born with HIV and no woman will die giving birth (MOHSS, 2012a:102-103).

A coordination structure was established for a multi-sectoral HIV response at national, regional and local levels and in workplaces. The overall multi-sectoral approach concentrated on prevention, treatment, care and support, impact mitigation and management and coordination. The medium terms plans called on all sectors to mainstream HIV in their plans, strategies, programmes and projects. The Office of the Prime Minister (OPM) coordinates and provides guidance on the Public Sector Response to HIV and AIDS. There are 33 public service offices, ministries and agencies (OMAs); all OMAS are guided by the Public Service HIV and AIDS Workplace Policy, with about ten out of 28 having specific Workplace HIV and AIDS Policies. All OMAs have plans to implement their activities, while 18 budget for their plans. Total population targeted with the Public Service Workplace programmes is 240 000 (staff members and dependents). The development of comprehensive national policy on employee wellness, for both the private and public sectors, will increase the scale of financial investment and contribution towards employee wellness and improved service delivery. The extension of the HIV and AIDS Workplace Programmes to Comprehensive Employee Wellness Programmes will assist in the elimination of discrimination and stigmatisation, and ensure effective management of chronic diseases at the place of work, including ART.

In June 2011, Namibia committed itself to continuing its active response to HIV and AIDS by endorsing the Political Declaration on HIV and AIDS: Intensifying our Efforts to Eliminate HIV and AIDS, at the UN General Assembly High Level Meeting on AIDS. The Political Declaration on HIV and AIDS runs parallel to the MDGs, with ten targets to be achieved by 2015, which support the achievement of MDG 6. In 2013, a consultative mid-term review of progress against these targets was completed and outlined the way towards achieving them.

The M&E system for HIV has expanded over time, with a well-established framework and effective organisational structure that includes different stakeholders, encompassing development partners, CSOs, FBOs and the private sector. Routine monitoring of the epidemic, such as through the HIV Sero Surveillance Survey, has been conducted every two years since 2002, and triangulation of data from different sources is carried out.

The paradigm shifts in HIV prevention have been based on lessons learned from the early stages of the epidemic. Namibia acknowledges that effective prevention strategies are as essential as all other components of the overall HIV response, and should continue to receive attention and resources equal to those for treatment and support. The overall prevention response is guided by evidence-based strategies to prevent STIs, reduce multiple concurrent partnerships (MCPs), promote voluntary medical male circumcision (VMMC) (rolled out to 30 district hospitals), promote condom use, home-based care, involvement of people living with HIV (PLHIV), and social and behaviour change. The programmes implemented have included information, IEC and use of the mass media at local, regional and national levels. Some interventions included MFMC, Window of Hope, FAWENA programme, Wings of Life, Communications for Behavioural Impact Strategy for HIV and AIDS (COMBI), interpersonal communication at workplaces, the Break the Chain (BTC) campaign (the first campaign to address MCP), NawaSport, the Stand Up campaign against alcohol misuse, VCT campaigns such as the National Testing Day, the Be Strong Get Tested campaign, the Condom Social Marketing and Distribution Programme (NASOMA), HIV control activities for commercial sex workers, prevention activities with men who have sex with men (MSM), special programmes for women and men in uniform, voluntary medical male circumcision and creating demand for it, PMTCT as well as male involvement in PMTCT, prevention of sexually transmitted infections (STIs), Bophelo! mobile wellness screening initiative, and safety of blood transfusion products. The BTC, implemented by Nawalife on behalf of the joint venture between the Ministry of Information and Communication Technology, MOHSS, the UN, United States Agency for International Development (USAID) and NGO partners, was the first runner up in the category Best Multi Channel Campaign at the AfriCOMNET 2010 Annual Awards of Excellence in HIV/AIDS Strategic Communication in Africa.

In addition to several interventions to encourage men and women of different ages to be tested for HIV, Namibia also has National Testing Days (NTDs) for HIV. Three have been held and at the first one in 2008, 30 000 people were tested and received their results. The number of people tested increased to 80 000 on NTD in 2009. In 2010 the NTD exceeded its target by 129 percent (MOHSS, 2010h:2).

Namibia has accelerated ART scale-up with high coverage, the adoption of the WHO 2010 guidelines for a CD4 count threshold of 350, replacement of AZT by Tenofovir as a first line drug, and achievement of a low percentage of the need for second line treatment (MOHSS, 2012a,:77). Antiretroviral treatment is now provided in 181 decentralised sites, which include 40 full ART sites, 111 outreach and 30 Integrated Management of Adult Illnesses sites, and reaches over 75 000 people (MOHSS, 2010g:9). Commendable strides have been made with PMTCT, HIV testing and community outreach as well. Furthermore, the recently launched National Elimination Plan for MTCT (2012) provides the way towards achieving zero new infections among children and keeping mothers alive.

The relationship between TB and HIV creates challenges and meeting these continues to be a high priority of Namibia’s HIV treatment care and support programme. This has led to the establishment of the TB/HIV Technical Working Group, responsible for coordinating TB and HIV response activities. The achievements in the coordinated TB/HIV response include the establishment of ART and TB guidelines and revisions thereof, trainings especially in co-management of HIV and TB, making prophylaxis for opportunistic infections available at all health centres, improvement in Isoniazed Preventive Therapy provision, and roll-out of HIV Quality Care (HIVQUAL) to more ART facilities.

Namibia is one of only a few countries in Africa that has a well-established social support system for children orphaned and made vulnerable by HIV and other social determinants. Monthly social grants have supported OVC to gain access to vital social services. Taking overall child poverty into consideration, Namibia is reviewing the current child grant system with a plan to expand it to include all vulnerable children.

Development partners have contributed extensively in the form of financial and technical support, which is greatly appreciated by the Namibian people. The two main external sources for funding and technical support are the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the President's Emergency Plan for AIDS Relief (PEPFAR). Other external support is provided by the UN, European Union/GIZ, and Spanish Cooperation for International Development. However, with the re-categorisation of Namibia as an upper-middle income country in 2009, several donor-funded concessional grants and loans will be reallocated to other countries, resulting in a scale-down of financial and technical support that is already beginning to be felt. Taking this into consideration, Namibia has drafted a Sustainability Plan based on the study Sustainable Financing for HIV/AIDS in Namibia: Managing the Transition towards a New AIDS Financing Strategy. The sustainability plan is based on Namibia using existing scarce resources more efficiently, strengthening partnerships with CSOs and engaging more actively in public-private partnerships. This will require the use of an investment approach which focuses on high impact interventions that deliver the greatest returns and reach key populations and those who are most vulnerable to and worst affected by HIV.

Namibia’s commitment to responding effectively to HIV is evident in the increased proportion of Government’s share of funding of the overall response. Namibia’s share of funding increased from 49.7 percent of total HIV and AIDS expenditure in 2009/10 to 60.4 percent in 2010/11 (MOHSS, 2013c:32). International assistance for HIV response decreased from 50.2 percent of total spending in 2009/10 to 39.5 percent in 2010/11 (MOHSS, 2013c:32). Overall sustainability is, therefore, strengthened by this increased financial commitment by Namibia.

Funding by donor type from 2007/08 to 2010/11

Funding by donor type from 2007-08 to 2010-11.JPG
MDG 6: Status at a Glance
GOALS AND INDICATORS BASELINE STATUS TARGET (2015) TARGET/ GOAL ACHIEVABLE?
MALARIA
Malaria mortality per 100 000 population
31 (1996)[7]
0.4 (2012)[8]
Halt and begin to reverse
On target
Proportion of children under 5 sleeping under insecticide-treated bed nets
10% (2000)[9]
34% (2009)[7]
Universal coverage by 2010
Not on target
Incidence of Malaria in 1 000 population
207 (1996)[7]
1.4 (2012)[8]
Halt and begin to reverse
Achieved


Current Status and Trends

The table above shows that Namibia is on track to halt and reverse malaria mortality, not on track with universal coverage of children under five years old sleeping under insecticide-treated nets (ITNs), and has already achieved the target to halt and reverse the incidence of malaria. The MDG goals are in line with the goals set in the MOHSS Strategic Plan 2010-2016 to reduce incidence of malaria to below 1 case per year per 1 000 people in all regions by 2016. Based on current trends, this target will be surpassed, with deaths being halted completely.

Namibia has done notably well in responding to malaria by reducing the number of people infected with malaria and treating those already infected. The current malaria incidence of 1.4 per 1 000 population is considerably lower than in 1996 (207 per 1 000 population) and 2000 (318 per 1 000) and 2004 (205 per 1 000). The graph below show a significant reduction of 99 percent in malaria incidence from 2001 to 2012. In addition to the above, severe malaria cases had already dropped by 98 percent over the eleven year period to 2012. Reported cases dropped from 521 067 to 3 163 over this period (MOHSS, 2013:2).

Incedence of malaria per 1000 population 1990-2015 Actual and Desired Trends.JPG

Based on the table below, the only region with increased out-patient department cases of malaria was the Karas Region. All other regions reported decreased out-patient department malaria cases, with the largest decrease reported in Kavango (91 percent). Caprivi has the highest number of reported cases, followed by Kavango and Omusati. The regions with the lowest reported cases are Hardap and Karas, which are not typically malaria-prone areas, and Omaheke. On the other hand, none of the regions reported an increase in in-patient department reported cases of malaria. The region with the highest number of in-patient malaria cases was Omusati, followed by Otjozondjupa and Caprivi. Since 2011, out-patient malaria cases reported have reduced by 78 percent, while there has been a 94 percent decrease in in-patient cases.

Out-patient department and in-patient department cases of malaria by region, 2012
Region OPD Cases IPD Cases
2011 2012 % Decline 2011 2012 % Decline
Caprivi
2 218
1 274
43
81
9
89
Erongo
34
18
47
9
0
100
Hardap
4
3
25
2
0
100
Karas
2
4
-100
4
0
100
Kavango
10 501
965
91
515
2
100
Khomas
57
43
25
43
8
81
Kunene
136
77
43
56
1
98
Ohangwena
413
196
53
48
4
92
Omaheke
37
13
65
3
0
100
Omusati
673
381
43
173
15
91
Oshana
128
49
62
4
3
25
Oshikoto
139
61
56
24
2
92
Otjozondjupa
67
34
49
22
13
41
Total
14 409
3 512
78.4
984
50
94.2

Source: MOHSS, 2013a:6


Malaria mortality follows the same trend as incidence, with significant declines over the past 11 years, falling from a high of 91.8 deaths per 100 000 population per year in 2001 to 50.4 in 2005 and 0.4 in 2012. Deaths fell by 89 percent between 2011 and 2012 (MOHSS, 2013a:6). Regional reductions vary considerably, with Kavango showing an out-patient department malaria case reduction of 91 percent and Hardap showing a reduction of 25 percent. As noted above, Khomas and Hardap are not malaria-prone. Oshana experienced three malaria deaths, while Caprivi reported one death and the remaining eleven regions did not report any deaths.

Malaria mortality rate per 100000 by year 1990-2015 Actual and Desired Trends1.JPG
Malaria mortality rate per 100000 by year 1990-2015 Actual and Desired Trends2.JPG
Malaria mortality rate per 100000 by year 1990-2015 Actual and Desired Trends3.JPG

Milestones

With the prioritisation of malaria as a serious health risk, the National Vector-Borne Disease Control Programme (NVDCP) was established a year after Namibia’s Independence under the auspices of the Primary Health Care Directorate. The NVDCP was later integrated into the Directorate of Special Programmes, with other leading diseases, HIV and TB. It is guided by an Integrated Malaria Policy, the Malaria Epidemic Preparedness and Response Plan, and the Integrated Vector Control Policy.

The NVDCP recently expanded its human resources in order to accelerate plans to eradicate malaria. Namibia has had no major malaria epidemics since 2005 and has now changed its overall response to malaria from a control programme to an elimination programme, a stage that only one in four SADC countries have been able to reach. Key to this approach is being more context-appropriate and focused on key areas, such as tackling districts with high infection rates first. This is evident in the shift of focus from the previous strategic plan to the current one. The previous malaria strategic plan (2003-2007) aimed to reduce malaria morbidity and mortality to a point where it would no longer be a major public health problem (MOHSS, 2010:5), while the aim of the current strategic plan (2010-2016) is to reduce the incidence of malaria to below 1 per 1 000 population in every district by 2016.

Recognising that malaria is a major developmental challenge and that gains can very easily be reversed through intermittent responses, the Government of Namibia funds the bulk of the NVDCP initiatives, including N$65 million per year for preventive and control activities, also covering administrative costs. In 2012, the Global Fund approved the Rolling Continuation Channel phase 2 and allocated US$9.8 million for three years. In addition to this, the Government of Namibia allocated an additional N$22 million for malaria elimination over the next three years. Strong partnerships have also been built with other development partners and international NGOs, such as the Society for Family Health (SFH), Development Aid from People to People, and Anglican Diocese/Nets for Life. Development partners who provide technical and programme support include the WHO, UNICEF and the Southern Africa Malaria Elimination Support Team.

Namibia has been implementing annual indoor residual spraying of houses since 1965, and has maintained a high coverage of 90 percent across eight malaria-prone regions. With support from the Global Fund, Namibia started using long lasting insecticide-treated nets from 2005 and has since distributed 600 000 of these nets free to those in need across nine regions.

As case management of malaria is extremely important, the NVDCP continues to build the capacity of staff. A training-of-trainers exercise was carried out with the intention that an additional 141 health workers would be trained by the original trainees. The NVDCP recruited four clinical mentors and two surveillance officers to support the malaria prone regions. One of these mentors was stationed in Caprivi due to the high number of cases there (MOHSS, 2013a).

Frequent and regular supervisory visits are undertaken for monitoring purposes. In addition, continuous research investigating malaria epidemiology is carried out at selected sites. A study on the prevalence of Schistosomiasis was carried out in two regions, Caprivi and Kavango, and showed that the prevalence in the two regions was between 10 and 49 percent.

Namibia plays a key role in the regional malaria response as it is spearheading the elimination campaign in the SADC region. Significant progress has been made towards the establishment of the Trans-Kunene Malaria Initiative along the border with Angola.

MDG 6: Status at a Glance
GOALS AND INDICATORS BASELINE STATUS TARGET (2015) TARGET/ GOAL ACHIEVABLE?
TUBERCULOSIS
TB cases notified per 100 000 population
657 (1997)[10]
545 (2011)[11]
<300
Not on target
% TB cases treated successfully
58 (1996)[12]
85 (2010)[11]
85
Achieved
Death rates (%) associated with TB
7 (2000)[11]
4 (2010)[11]
<5
Achieved


Current Status and Trends

The overall incidence of TB has been reduced in many countries including Namibia. The current TB incidence in Namibia is 723 per 100 000 population after steadily declining since the early 2000s (WHO, 2012). In 2011, there were 566 TB cases notified per 100 000 population (MOHSS, 2011b). Namibia reported an increase in TB cases notified from the mid-nineties to the early 2000s, after which a steady reduction was reported from 2004 (822 per 100 000 population) to 2011 (566 per 100 000 population). The overall decline in notified cases is slowing down from a decline of 10 percent between 2007 to 2008 to 5 percent between 2009 and 2010. The MOHSS noted that, “the decline in the number of cases notified over the past five years…suggests a decrease in TB incidence in the country, although this cannot be confirmed in the absence of TB disease prevalence surveys” (MOHSS, 2011b:2). The graph on the right shows that Namibia is not on track to achieve the 2015 MDG of 299 TB notified cases per 100 000 population. In addition, multi-drug resistant TB and extensively drug resistant TB across all regions exacerbate the challenges faced by public and private health facilities in prevention and treatment.

TB cases notified for all forms of TB per 100000 population 1990-2015 Actual and Desired Trends.JPG

Slightly different trends have been observed for different types of TB – new sputum smear negative TB, smear positive TB and extra-pulmonary TB (EPTB). The decrease in new cases of sputum smear negative TB is higher than that of smear positive TB, which is a concern, especially taking into consideration the high HIV prevalence in the country. “The number of cases of EPTB has remained relatively constant between 2006 and 2011, possibly as a result of scale up of ART with the consequent decrease in the risk of developing EPTB.” (MOHSS, 2011b:2.)

Age-sex distribution of new smear positive TB cases 2011.JPG

In 2011, it was found that more males (56 percent) than females (44 percent) were tested positive, while those aged between 25 and 34 were more prone to infection than younger (0 to 14 years) and older (55+ years) people. However, more females than males tested positive in the 0 to 24 years group, following similar trends noted in HIV infection. The regions with the highest case notifications were Karas (953 per 100 000 population) followed by Hardap (837) and Omaheke (833). The lowest TB case notification was reported in Omusati (340 per 100 000 population), followed by Kunene (341) and Ohangwena (428).

Case notification rates by region 2011.JPG

TB is the most common life-threating opportunistic disease amongst HIV positive people. The graph below shows that more people who are diagnosed with TB are tested for HIV and know their status, while the proportion of people with TB who are HIV positive has been on a steady decline from 59 percent in 2007 to 50 percent in 2011. “Kunene maintained the highest regional HIV testing rate among TB patients (99 percent), while Khomas and Caprivi (region with the highest HIV prevalence) had the lowest proportion of patients with a known HIV status.” (MOHSS, 2011b:13)

TB and HIV 2007-2011.JPG

The international target for TB case management is a treatment success rate of at least 90 percent among new patients with infectious TB. However, the MDG for Namibia is 85 percent by the year 2015. Namibia reached a TB treatment success rate of 85 percent in this category of patients for the patients who commenced treatment in 2009, six years ahead of the 2015 target, and remained constant for 2010. The defaulter rate was 3 percent, while the treatment failure and death rates were 4 percent and 5 percent respectively (MOHSS, 2011b:x). However, it should be noted that the success rate for retreatment was low, at 71 percent in 2010, “necessitating greater efforts towards screening for TB drug resistance both at the beginning of treatment as well as at any point during treatment should the patient remain smear-positive” (MOHSS, 2011b:6). The failure rate for those on retreatment was 11 percent in 2010, while 10 percent died. The death rate associated with TB follows similar trends to those for TB cases notified, with a steady reduction from 2001, from eight deaths to four deaths in 2010. This means that Namibia had achieved the MDG goal of less than five deaths associated with TB by 2010, five years ahead of the 2015 target.

Proportion TB cases treated successfully 1990-2015 Actual and Desired Trends.JPG
Death rate associated with TB percentage 1990-2015 Actual and Desired Trends.JPG


Milestones

After the Independence of Namibia in 1990, the MOHSS included the TB programme under the broader Primary Health Care Framework. Tuberculosis is highlighted as a health priority under the current MOHSS Strategic Plan 2009-2013. The National TB and Leprosy Programme (NTLP) sits strategically in the Directorate of Special Programmes of MOHSS together with the NACOP due to the interrelationship with HIV and resultant collaborative activities. “Mainstreaming TB in HIV/AIDS planning and management and vice versa is now more prominently reflected in the respective strategic documents” (MOHSS, 2010c:14) while implementation is commendable. Tuberculosis is regarded as a development challenge and requires a multi-sectoral response similar to the response to HIV. Therefore TB responses have been included in existing multi-sectoral coordinating structures for HIV.

The WHO, one of the key strategic partners in the fight against TB, supported Namibia to carry out the first situation analysis shortly after Namibia’s Independence. Based on the findings of this analysis, the National Tuberculosis Control Programme (NTCP) was established. In 1991, NTCP adopted the WHO’s Directly Observed Treatment-Short Course (DOTS) and reached national coverage by 1996. Several policy documents and guidelines for the management of TB have been and continue to be developed to respond to TB effectively, especially in relation to multiple drug resistance and the development of new medical regimes, such as fixed dose tablets. Drug resistance has been managed since the 1990s, with the first guidelines being released in 1995.

Government’s commitment to drive TB responses effectively and efficiently is evident in the importation of health specialists and technical assistance. Namibia continued to build an interactive relationship with key development partners such as WHO, KNCV TB Foundation, USAID, PEPFAR, UNAIDS, Centers for Disease Control, ITECH, IULTD, the Global Fund, MSH and TLMI. These relationships have played a key role in continued efforts to devise innovative responses for an ever changing epidemic. They are supported through inter-programme, inter-divisional and inter-agency collaboration, multi-sectoral collaboration, and international collaboration. The national coordinating structure follows a multi-sectoral approach, with the first coordinating body, the National Steering Committee for Tuberculosis, being established in 2005. Through this multi-sectoral committee, Namibia was able to solicit funding from several sources, such as WHO, USAID and the Global Fund. However, with external funding slowly decreasing, the Government of Namibia is assessing various avenues to continue to fund TB programmes from within.

Namibia has done well in terms of engaging the community in TB response strategies. Sensitisation and mobilisation of communities have paid off in terms of early case identification and adherence to treatment. The latest strategic plan acknowledges the important role of community-based DOTS services and community workers in the significant improvement in treatment success rates, while the work of community workers contributed to reduction in stigma and discrimination. The Community Health Committees are active in most cases, but need technical support to maintain momentum. “The use of community field workers, especially ‘field DOTS promoters’ and ‘lifestyle ambassadors’ as part of community TB care scale up has been remarkable and critical to the expansion of patient-centered delivery of treatment, including DOTS at community level.” (MOHSS, 2010c:50)

Based on lessons learned and in line with the current strategic plan of the MOHSS as well as international commitments such as the MDGs, the Second Medium Term Strategic Plan for Tuberculosis and Leprosy 2010-2015 aims to achieve the following:

  • High quality TB DOTS and leprosy services expanded and enhanced
  • Increased access to high quality TB/HIV treatment and care interventions
  • Programmatic management of drug resistant TB improved and scaled up
  • General health systems strengthened and effectively supporting TB and leprosy services
  • Partnerships for TB control and leprosy eradication strengthened
  • Communities and people with TB and leprosy empowered.


References

  1. 1.0 1.1 MOHSS, 2012c:12 (2012 HIV Sentinel Survey)
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 MOHSS, 2008 (2006/07 NDHS)
  3. 3.0 3.1 3.2 3.3 3.4 MOHSS, 2003 (2000 NDHS)
  4. 4.0 4.1 MOHSS, 2012B:69 (NSF Progress Report, 2010/11
  5. Prevalence is based on HIV sentinel surveys carried out every two years among adult pregnant women visiting antenatal clinics. “To calculate national prevalence the ANC prevalence must be adjusted to account for males and other women that are not represented in the ANC surveillance hence the importance of modeling.” (MOHSS, 2012d:7). The Spectrum Group of Models is used to give estimates of adult prevalence used here in the report.
  6. Based on the 2012 Sentinel Survey as the 2011/12 Estimate and Projects did not provide prevalence broken done by age category in the main report.
  7. 7.0 7.1 7.2 Ohahandja Meeting Report, 2013
  8. 8.0 8.1 MOHSS, 2013a (2012/13 National Vector-Borne Diseases Control Programme Annual Report)
  9. MOHSS, 2003 (2000 NDHS)
  10. NPC, 2008d (2008 (MDGR)
  11. 11.0 11.1 11.2 11.3 MOHSS, 2011b (2010-2011 Annual Report, NTLP)
  12. NPC, 2010b (2010 MDGR)