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ASSESSMENT OF THE WORLD HEALTH
ORGANIZATION EARLY WARNING
INDICATORS OF HIV DRUG RESISTANCE
IN NAMIBIA FOR PUBLIC HEALTH
ACTION, 2015
Nicholus Mutenda1, Tuli Nakanyala1, Ndapewa Hamunime1, Tadesse Mekonen1, Francina Tjituka1, Salomo
Natanael1, Greatjoy Mazibuko2, Samson Mwinga2, David Mabirizi3 , Evans Sagwa2, Helena Walkowiak4,
Alexandra Kiesling5, Samuel Aptekar5, Michael R. Jordan5,6, Steven Y. Hong5,6
1Directorate of Special Programmes, Republic of Namibia Ministry of Health and Social Services,
Windhoek, Namibia, 2Systems for Improved Access to Pharmaceuticals and Services program,
Management Sciences for Health, Windhoek, Namibia, 3Systems for Improved Access to Pharmaceuticals
and Services program, Management Sciences for Health, Arlington, USA, 4Systems for Improved Access to
Pharmaceuticals and Services program, Management Sciences for Health, New York USA, 5Department of
Public Health and Community Medicine, Tufts University School of Medicine, Boston, USA, 6Division of
Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, USA
Abstract no. TUPDB0101

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Background
• Early warning indicators (EWIs) of HIV drug resistance
(HIVDR)
– foundational element of the World Health Organization
(WHO) public health strategy to minimize and monitor
emergence of HIVDR in countries rapidly scaling up
antiretroviral treatment (ART)
– site-specific, quality-of-care indicators that assess factors
associated with virological failure and emergence of HIVDR
– identify gaps in service delivery for which corrective action can
be taken at the ART site or program level
– provide necessary program context for interpretation of WHO
surveys of HIVDR
– should be monitored annually at all treatment sites and
integrated into ART program M&E and continuous quality
improvement initiatives
• Namibia has instituted a routine EWI monitoring system
and developed HIVDR survey strategies

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Methods
• In 2015, Namibia abstracted the following WHO EWIs:
– On-time Pill Pick-up
– Retention in Care at 12 months
– Pharmacy Stock-outs
– Dispensing Practices
– Viral Load Suppression at 12 months
– Viral Load Completion at 12 months
• EWIs abstracted from adult and paediatric patients from all ART
sites in the state health sector: 50 main ART sites and 163
outreach points
• WHO-recommended definitions and targets used, based on three
classifications:
– green (excellent performance, achieving desired level)
– amber (fair performance, not yet at desired level)
– red (poor performance, below desired level)
– grey (insufficient data)

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Geospatial location of 213 ART sites for EWI monitoring, 2015

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Results
• On-time Pill Pick-up:
– Adults: 45% of sites (excellent >90% or fair 80-90%)
– Children: 40% of sites
• Retention in Care at 12 months
– Adults: 54% of sites (excellent >85% or fair 75-85%)
– Children: 38% of sites
• Pharmacy Stock-outs
– Adults: 5% of sites (excellent 100% of months with no stock-outs)
– Children: 14% of sites
• Dispensing Practices
– Adults: 97% of sites (excellent 0% mono- or dual-therapy)
– Children: 91% of sites
• Viral Load Suppression at 12 months
– Low rates of Viral Load Completion among patients eligible for routine
viral load testing significantly affected monitoring of Viral Load
Suppression

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Conclusion
• Namibia has successfully institutionalized EWI monitoring
into routine ART program functioning
• Strengthening patient adherence, retention in care, and
ensuring the continuous availability of ART medicines are
all high priorities to minimize emergence of HIVDR and
achieve the 90-90-90 (HIV epidemic control) goals
• Improving routine viral load monitoring and data
capturing is a priority to enable monitoring of viral load
suppression rates
• As a result of these data, program leaders and healthcare
providers in regions throughout the country are
implementing service quality improvement projects and
operational research to improve patient care and
minimize the emergence of HIVDR