Maintaining ART services during COVID-19 border closures: lessons learned in Namibia
Authors: Linea Hans, Steven Y Hong, Laimi S N Ashipala, Leonard Bikinesi, Ndapewa Hamunime, Jacques W N Kamangu, Eliphas J Hatutale, Eric J Dziuban
Journal: The Lancet HIV (2020)

The Namibian Ministry of Health estimates that approximately 5000 Angolans live along the 1376 km shared border between Angola and Namibia, and receive antiretroviral therapy (ART) in Namibia free of charge (unpublished). Shortly after Namibia's first documented cases of COVID-19 on March 14, 2020, Namibia's President declared a state of emergency and closed international borders, restricting movement of nearly all individuals and affecting the provision of health services to Angolan patients who had been receiving ART services in Namibia. The Namibian Ministry of Health and Social Services, with support from US Centers for Disease Control and Prevention, implemented a strategy for HIV treatment continuity, while limiting patient volumes at ART facilities to minimise risk of COVID-19 exposure. The strategy included coordinated information dissemination, collaboration between regional and local governments, and community points for dispensing ART at the border with Angola. This strategy also included an emphasis on multimonth (3–6 months) dispensing of ART and tracing patients who missed appointments by telephone to link them back into care. The Ministry of Health and Social Services coordinated information dissemination on managing patients receiving ART via the virtual mentorship platform provided by the Project Extension for Community Healthcare Outcomes (ECHO). Namibia was one of the first African countries to adopt Project ECHO in 2015 to connect remote clinical sites with central specialists by use of a collaborative model of medical education and care management.1Struminger B Arora S Zalud-Cerrato S Lowrance D Ellerbrock T Building virtual communities of practice for health.Lancet. 2017; 390: 632-634Summary Full Text Full Text PDF PubMed Scopus (50) Google Scholar Because all major district hospitals and high-volume health-care centres (n=40) in Namibia currently use the platform, Project ECHO enabled rapid communication and tele-mentoring across all regions along the border, despite travel restrictions. Specific border WhatsApp groups also were set up to facilitate real-time communication between Namibian and Angolan health-care workers, regional Namibian Ministries of Health, and implementing partners. Collaboration between the Ministry of Health and Social Services, the Ministry of Safety and Security, the Ministry of Defence, regional and local governments, immigration officials, and police from both sides of the border ensured that individuals seeking health services in Namibian clinics received ART services. Through the strong collaboration with the Angolan police force, patients were informed where and when to collect ART at the border through radio messaging and local headmen (ie, tribal leaders). Community ART dispensing at the border with Angola was established at 24 sites to ensure that Angolan patients could access ART (appendix p 1). Outreach teams consisted of ART or tuberculosis nurses, pharmacists or pharmacy assistants, health assistants, and drivers. At border outreach points, teams provided comprehensive services, including ART dispensing, pre-exposure prophylaxis, HIV testing services, clinical consultations for ART and tuberculosis, and primary health-care services. Services were provided in prefabricated structures, makeshift sites under trees, and from vehicles. From March 28 to June 15, 2020, 3674 pill pick-ups were done at these border outreach sites. 3564 (97%) of these pick-ups provided patients with at least 2 months of pills and 2498 (68%) provided patients with at least 3 months of pills. Although border closures related to COVID-19 hindered Angolan patients' access to ART services, Namibia quickly adapted the HIV programme to provide uninterrupted services. Public health strategies such as these can serve as a model for implementation in other settings to avoid interruption of access to health services, thereby mitigating the potential negative impact of this pandemic or others in the future. We declare no competing interests. This Correspondence has been supported in part by the President's Emergency Plan for AIDS Relief through the Centers for Disease Control and Prevention, under the terms of GH002175. The findings and conclusions in this Correspondence are those of the authors and do not necessarily represent the official position of the funding agencies. Published by Elsevier Ltd. Download .pdf (.12 MB) Help with pdf files Supplementary appendix Building virtual communities of practice for healthAdvances in medical research and innovation mean little if they do not reach the patients who need them. Too often, specialised medical knowledge remains within the walls of academic and tertiary care centres in capitals and major cities, inaccessible to much of the world's population due to geographical distance and economic disparity. To "ensure healthy lives and promote well-being for all at all ages", UN Sustainable Development Goal 3 , a more efficient and equitable way to disseminate new scientific knowledge and evidence-based expertise is needed. Full-Text PDF