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Rapid Adaptation of HIV Treatment Programs in Response to COVID-19 — Namibia, 2020
Weekly / October 23, 2020 / 69(42);1549–1551
Steven Y. Hong, MD1; Laimi S.N. Ashipala, MBChB2; Leonard Bikinesi, MBChB2; Ndapewa Hamunime, MBChB2; Jacques W.N. Kamangu, MBChB2; Ashley Boylan, MPH1; Edwin Sithole, MBChB1; Ismelda C. Pietersen, MPH1; Gram Mutandi, MBChB1; Catherine McLean, MD1; Eric J. Dziuban, MD1 (View author affiliations)
View suggested citationNamibia is an upper-middle income country in southern Africa, with a population of approximately 2.5 million (1). On March 13, 2020, the first two cases of coronavirus disease 2019 (COVID-19) in Namibia were identified among recently arrived international travelers. On March 17, Namibia’s president declared a state of emergency, which introduced measures such as closing of all international borders, enactment of regional travel restrictions, closing of schools, suspension of gatherings, and implementation of physical distancing measures across the country. As of October 19, 2020, Namibia had reported 12,326 laboratory-confirmed COVID-19 cases and 131 COVID-19–associated deaths. CDC, through its Namibia country office, as part of ongoing assistance from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) provided technical assistance to the Ministry of Health and Social Services (MoHSS) for rapid coordination of the national human immunodeficiency virus (HIV) treatment program with the national COVID-19 response.
With support from PEPFAR since 2004, Namibia is on the verge of HIV epidemic control: 95% of persons with HIV infection know their status; 95% of these persons are receiving antiretroviral therapy (ART); and among these, 92% have achieved viral load suppression (≤1,000 copies of viral RNA/mL) (2). Because the COVID-19 pandemic has the potential to compromise Namibia’s ART program efforts, MoHSS prioritized providing life-saving ART while reducing patient volume in ART facilities to reduce the risk for COVID-19 exposure in advance of a possible broader COVID-19 outbreak in Namibia.
Regional MoHSS ART clinical mentors, who are experienced ART physicians supporting healthcare workers in each of the 14 regions, served as points of contact to implement rapid adjustments to the ART program. New national guidance, coordination, and feedback were communicated through the Project Extension for Community Healthcare Outcomes (ECHO) virtual mentoring platform (3); Namibia was among the first African countries to adopt Project ECHO in 2015. During March 17–April 21, MoHSS conducted seven communication sessions using the Project ECHO platform with 760 sites and 2,068 health care providers. Because all major district hospitals and high-volume health care centers in the country use the ECHO platform, rapid communication and telementoring across all regions was possible, despite travel restrictions.
MoHSS, with CDC support and in alignment with forthcoming PEPFAR guidance (4), quickly developed a plan to minimize the frequency of patient contact with the health care system and reduce burden on facilities. The plan consisted of facility readiness, multimonth dispensing (MMD) of ART, and the expansion of community ART dispensing.
Facility readiness included plans for screening and triaging patients. ART patients were first screened for COVID-19–compatible signs and symptoms* upon arrival at the health facility. Those with symptoms were isolated and tested for SARS-CoV-2, the virus that causes COVID-19, by polymerase chain reaction (PCR) testing of specimens obtained with a nasopharyngeal swab and, if hospitalization was not required, were asked to self-isolate while waiting for results. In an effort to avoid overcrowded waiting areas, and thereby possible SARS-CoV-2 transmission, asymptomatic patients were triaged to receive fast-track refills without entering the facility or quick, small group clinical consultations for dispensing MMD. Patients aged ≥50 years and those with underlying medical conditions (5) received expedited services. MoHSS provided recommended personal protective equipment (6) to clinic staff members and symptomatic patients.
Four-month MMD of ART was implemented by assessing the national stock and adjusting ART guidance to maximize available stock and ensure optimal regimens. To ensure treatment continuity, the National Central Medical Store distributed 4–6 months’ supply of stock for 166,237 (97%) of 171,830 total patients receiving ART to health care facilities in all regions. Emergency procurement was activated to ensure that a 12-month supply of ART stock would be available in the country.
Community ART dispensing was expanded through 1) newly established community-based ART points, 2) primary health care outreach points, 3) community adherence groups, 4) mobile vans, and 5) home delivery. Outreach points placed at the borders were especially important for Angolan patients seeking ART refills in Namibia despite border closures. A national ART hotline was established to assist patients who experienced difficulty accessing services.
Other HIV treatment services were also adjusted to prevent transmission of SARS-CoV-2 (Table). Programs minimized patient contact with health care facilities to limit possible exposure. Community programming supported physical distancing and used alternative methods of communication, including virtual platforms such as Zoom or Skype, phone calls, social media, and WhatsApp Messenger, a mobile application for smartphones. Group activities were limited in size according to Namibia national regulations.
Namibia has rapidly implemented public health measures to mitigate SARS-CoV-2 transmission, which allows additional time to adequately prepare the health care system for a potential surge in COVID-19 cases. The ART program has adapted to ensure the continuity of essential HIV services while maintaining a safe health care environment for clients and staff members during the COVID-19 pandemic. Efforts are underway to evaluate the implementation of these initiatives across sites and the impact on programs. These public health strategies could be implemented in other settings where COVID-19 might threaten the HIV treatment program when the public health providers and governments are willing to use new technologies and novel strategies to maintain patient care.
Corresponding author: Steven Y. Hong, [email protected].
1Division of Global HIV and TB, Center for Global Health, CDC; 2Ministry of Health and Social Services, Namibia.
All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.
* Fever or temperature ≥100.4°F (38.0°C), cough, shortness of breath, weakness, muscle aches, chills, vomiting or diarrhea, headache, chest pain, new loss of taste or smell.
References
- Namibia Statistics Agency. Namibia population and projections 2011–2041; Windhoek, Namibia: Namibia Statistics Agency; 2014. https://nsa.org.na/page/publications
- United States President’s Emergency Plan for AIDS Relief. Namibia country operational plan (COP) 2020 strategic direction summary. Washington, DC: US Department of State; 2020. https://copsdata.amfar.org/SDS/2020/Namibia.pdf
- Struminger B, Arora S, Zalud-Cerrato S, Lowrance D, Ellerbrock T. Building virtual communities of practice for health. Lancet 2017;390:632–4. CrossRef PubMed
- United States President’s Emergency Plan for AIDS Relief. PEPFAR technical guidance in context of COVID-19 pandemic. Washington, DC: US Department of State; 2020. https://www.state.gov/wp-content/uploads/2020/10/10.07.2020-PEPFAR-Technical-Guidance-During-COVID.pdf
- Chow N, Fleming-Dutra K, Gierke R, et al.; CDC COVID-19 Response Team. Preliminary estimates of the prevalence of selected underlying health conditions among patients with coronavirus disease 2019—United States, February 12–March 28, 2020. MMWR Morb Mortal Wkly Rep 2020;69:382–6. CrossRef PubMed
- CDC. Coronavirus disease 2019 ( COVID 19): using personal protective equipment (PPE). Atlanta, GA: US Department of Health and Human Services, CDC; 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html
Abbreviations: ART = antiretroviral therapy; COVID-19 = coronavirus disease 2019; MMD = multimonth dispensing; PPE = personal protective equipment; Project ECHO = Extension for Community Healthcare Outcomes.
* OraSure Technologies. http://www.oraquick.com.
Suggested citation for this article: Hong SY, Ashipala LS, Bikinesi L, et al. Rapid Adaptation of HIV Treatment Programs in Response to COVID-19 — Namibia, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1549–1551. DOI: http://dx.doi.org/10.15585/mmwr.mm6942a6.
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