Master Thesis by Olaf Buchholz

PRESERVATION OF LIFE CENTERS FOR DISEASE CONTROL AND PREVENTION OLAF BUCHHOLZ MASTER THESIS DIA 2016/17 1st. SUPERVISOR JORIS FACH 2nd. SUPERVISOR ROGER BUNDSCHUH

2

Acknowledgement In these few lines I would like to thank a couple of people who have made this Thesis possible.

First and foremost I offer my sincerest gratitude to my supervisor, Joris Fach, for his patient guidance, encouragement and advice he has provided throughout my time as his student. I have been extremely lucky to have a supervisor who cared so much about my work. I would also like to thank all the members of staff at Hochschule Anhalt who helped me in my supervisor’s absence.

I am also very grateful to Andrea, my partner, for her constant motivation, encouragement and for her love during these years. Many thanks go to my parents, my sister and the rest of the family, for their wise counsel and sympathetic ear when I needed it and for feeling so close despite being so far away.

Last but not least I would like to send out a special thanks to Hugo and Angi Scheepers for all their emotional support as well as the financial aid. The opportunity to study abroad would not have been possible if it wasn’t for you. I truly appreciate what you have done for me and I will be forever grateful.

3

4

CONTENT PAGE 6

RECOVERY BY JORIS FACH

10 INTRODUCTION 16

HIV / AIDS

30 PREVALENCE 48 TREATMENT 66

PATIENT NEEDS

78

HIV SERVICES

88 LOCATION 114 PROGRAMME 148 THE BRIEF 154

THE PROGRAMME

158

DESIGN INTENTIONS

164

DESIGN STRATEGIES

176

DESIGN CONCEPTS

182 DRAWINGS 206 MATERIAL COLLAGE 212 MODELS 220 MODULAR LAYOUTS 236 APPENDIX 244 BIBLIOGRAPHY

5

6

RECOVERY

7

In a health obsessed society, in which fitness clubs and organic food stores spring up at every street corner, the loss of agility and productivity is not an option. Hence, whenever bad luck does strike, it causes daily routines to collapse. Recovery always takes too long and lasting dysfunctions are ruinous. As such, our health has become part of a social equation, differentiating often underfunded public care from exclusive private rehabilitation centers. Additionally, the ownership of health-related data has become highly sensitive, as it is utterly valuable to both pharmaceutical companies, as well as future employers.

Overall, however, the health care industry is one of the most reliably growing ones of recent years. Hospitals have expanded into imposing conglomerates of impenetrable bigness that often fail to connect to their context on almost every level. Pharmaceutical enterprises treat themselves to lush campuses, marking their newly acquired power and influence.

Keeping all of the above in mind, we will commence the semester by looking at the human body itself, understanding its organic functions and amazing resilience, but also study sports injuries, chronic diseases, psychological instabilities, drug addictions and their respective treatments. As the radius of mobility become restrained, the design of immediate surroundings becomes crucial. We will thus speculate on productive environments for recovery, imagining paradisiacal states of urban arcadia in which physical rehabilitation overlaps with exciting cultural programs, making every step of a recovery an exciting one for both body and mind.

9

10

INTRODUCTION

11

12

HIV, the virus that causes AIDS, is one of the world’s most serious health and developmental challenges. Since the onset of the epidemic in the 1980s, more than 70 million people have been infected with the virus and about 35 million people have died. Currently about 36.7 million people are living with HIV. The burden of this epidemic continues to vary considerably between countries and regions. Sub-Saharan Africa remains most severely affected, with nearly 1 in every 25 adults (4.4%) infected, accounting for nearly 70% of the people living with HIV worldwide (World Health Organization, 2016).

Namibia, my birthplace and home, is one of those Sub-Saharan countries highly affected by the virus. It currently has the 5th highest HIV prevalence rate in the world, with a total of 13,3% of the population infected. This has drastically impacted on the countries health indicators, posing serious developmental challenges. Providing universal access to HIV services and infrastructure, has been a priority for the Namibian government for the last ten years and 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 and financial investment (World Health Organization, 2014).

The proposal for this research study will be an introduction of new architectural interventions, that will seek to provide comprehensive and quality treatment, counselling, prevention campaigns, testing as well as care and support for those already infected by HIV/AIDS and the ones that are at risk. Due to the fact that Namibia is so sparsely populated, I want to focus on the rural communities, as most of them have little access to health services. Since this adresses the whole country, the proposal will consist of a masterplan, introducing several interventions, spread throughout Namibia´s 13 regions. In total there will be 11 new facilities, composed of a central hub and 10 smaller modules. The central hub will be located in the capital city of Windhoek and will serve as a supplier to all the smaller modules, providing them with health staff, medication and support. In return these modules will reach out to all the remote areas by means of mobile clinics, covering identified areas within the country.

Apart from the necessacity and function of these facilities, the architecture will envision a sustainable and feasible approach, making use of affordable local materials and building techniques.

13

14

“ Abantu Abaafa! – People are dying!

An elderly woman calls to us from a village in Uganda. She says what everybody knows.

People are dying from AIDS. Her thin arms are held out imploringly.

She is distraught. The skin hangs in folds where once there was flesh. She is in her eighties and cares for her many orphaned grandchildren.

People are dying – they are and were and will be her children and grandchildren. She cares for them, but when she dies they are orphaned once again. They grow up. They too may become infected and die of AIDS. No one listens.“ (Barnett & Whiteside 2002, 3)

15

16

HIV/AIDS

17

What is HIV / AIDS? HIV stands for human immunodeficiency virus. If it is left untreated, it can lead to the disease called AIDS (acquired immunodeficiency syndrome).

Unlike other viruses, the human body can’t get rid of HIV completely.

So once you have picked up the virus, you have it for life. HIV attacks the white blood cells in the body, which help the immune system fight off any infections. If however the virus is not treated, it can greatly reduce the number of these cells, making the person more vulnerable to pick up a disease. Over time, HIV can destroy so many of these cells that the body can’t fight off infections and diseases anymore. These opportunistic infections take advantage of a very weak immune system and signal that the person has AIDS, the last state of HIV infection. (U.S. Department of Health & Human Services, 2016) 1. Infected with virus 2. Virus attacks the T-cells 3. HIV copies itself and starts attacking other uninfected T-cells

1

18

2

HIV / AIDS

3

Where does HIV come from?

Research shows that HIV first infected humans in sub-Saharan Africa.

Scientists believe that a chimpanzee in Central Africa was the source of HIV infection in humans. They are convinced that the chimpanzee version of the immunodeficiency virus (called simian immunodeficiency virus, or SIV) was most likely transmitted to humans and mutated into HIV when humans hunted these chimpanzees for meat and came into contact with their infected blood (Gallant 2016, 14). Studies show that HIV may have jumped from apes to humans as far back as the late 1800s. Over decades, the virus slowly spread across Africa and later into other parts of the world (AVERT,2016).

HIV

HIV / AIDS

19

How is HIV spread?

The HIV virus can only be transmitted through specific activities. The most common actions are: 1. Sexual intercourse 2. Mother to child transmission 3. Needle or syringe use 4. Blood transfusion There are only certain body fluids from a HIV infected person that can transmit the virus such as: Blood, semen (cum), pre-seminal fluid (precum), rectal fluids, vaginal fluids and breast milk (U.S. Department of Health & Human Services, 2016).

These body fluids must come into contact with a mucous membrane or damaged tissue or be directly injected into your bloodstream (by a needle or syringe) for transmission to occur.

1

20

2

3

HIV / AIDS

4

Not spread by?

HIV cannot survive long outside the human body (such as on surfaces) and it does not reproduce outside a human host. It is not spread by: 1. Mosquitoes, ticks or other insects 2. Closed-mouth or “social” kissing with someone who is HIV-positive 3. Sharing toilets 4. Other sexual activities that don’t involve the exchange of body fluids such as shaking hands, hugging, sharing dishes/drinking glasses Thus, compared to many other viruses, HIV is not easily passed on but great care and responsibility still has to be taken.

1

2

3

HIV / AIDS

4

21

Stages of infection 1. Early stage of HIV Some people may experience a flu-like illness within 2-4 weeks after HIV infection, but others may not feel sick during this stage at all. During this time, HIV infection may not show up on an HIV test, but people who have it are highly infectious and can spread the infection to others.

2. Chronic HIV infection After the early stage of HIV infection, the disease moves into a stage called “chronic HIV infection”. During this stage, HIV is still active but reproduces at very low levels. People with chronic HIV infection may not have any HIV-related symptoms, or only mild ones. For someone who is not taking medicine to treat the virus, this period can last a decade or longer, but some may progress through this phase faster.

3. AIDS AIDS is the final stage of HIV infection. At this point the virus has damaged the immune system so much, that the body can´t fight off opportunistic infections any longer. Without treatment, people with AIDS typically survive about 1-3 years (AIDSinfo, 2016).

Years

Infection

Weeks

1

22

2

HIV / AIDS

3

Other infections related to HIV / AIDS People that have strong immune systems can be exposed to certain viruses or bacteria without having any reaction to them. However, people that live with HIV/AIDS can face serious health threats from what are known as “opportunistic” infections (OIs). These infections are called “opportunistic” because they take advantage of your weakened immune system, and they can cause devastating illnesses. They are the most common cause of death for people with HIV/AIDS. (U.S. Department of Health & Human Services, 2010) This list shows some of the most common Opportunistic infections that are considered AIDS-defining conditions: 1.Tuberculosis 2.Pneumonia 3.Invasive cervical cancer 4.Toxoplasmosis 5.Cryptococcal meningitis 6.Herpes simplex: chronic ulcer(s) or bronchitis 7.Histoplasmosis Worldwide, tuberculosis is the most common infection among people living with HIV. It can be very serious and if it is not treated, it can kill.

HIV / AIDS

23

How do you know if you are infected?

Despite the flu like symptoms at the beginning of the infection a person cannot and should not rely on them to tell whether he/she has HIV. The only way to know for sure if you have HIV is to get tested. Knowing your status is important because it helps a person make healthy decisions to prevent getting or transmitting HIV and to immediately take medication.

Flu-like symptoms for ca. 4 weeks

No symptoms for ca. 10 years

Weight-loss dying 1-3 years

Due to the lack of symptoms a lot of people dont know that they have picked up the virus and therefore don´t bother to get tested. These people are at risk of developing AIDS or of passing the virus on to others at a huge cost to themselves and to society. Its thus so vital to get the word out and to give everyone access to proper counselling and education.

36,7 million people are living with HIV globally

40% dont know their status

24

HIV / AIDS

know HIV =no HIV HIV / AIDS

25

A global timeline of the virus Cases of a rare lung infection found in five young men in Los Angeles

First commercial blood test

The epidemic gets the name

1981

Generic forms of HIV/AIDS drugs sold for much cheaper

1982

1984

HIV/AIDS is the 4th biggest cause of death worldwide and

23 million

people had HIV worldwide

living with HIV globally

1999

1997

1996

17% decline in HIV infections

54% of people receive treatment

2009

2011

Establishment of the United States President’s Emergency Plan For AIDS Relief (PEPFAR), with a $15 billion budget to fight AIDS

2002

2003

(Sigall K. Bell 2011, Timeline)

26

30 million

1985

number one killer in Africa

2001

Global Fund donates $600 million

“AIDS”

The link between HIV and AIDS was established

HIV / AIDS

reported 38,401 cases of AIDS

First antiretroviral medication introduced

400,000

1986

1987

1989

85 countries had

HIV cases worldwide

Freddie Mercury died of AIDS

FDA approved highly active antiretroviral treatment

2.5 million AIDS cases globally

1995

1993

1991

Early initiation of antiretroviral treatment reduced the risk of HIV transmission by 96%

people are living with HIV

35 million

All HIV patients should receive treatment regardless of their stage of infection

2012

2013

2015

HIV / AIDS

27

What the world says about HIV History will judge us on how we respond to the AIDS emergency in Africa....whether we stood around with watering cans and watched while a whole continent burst into flames....or not.

Bono

Stigma hurts. Because of AIDS, children are bullied, isolated and shut out of school. They are missing out on education. They are missing out on medicines. Children are missing your love, care and protection. Join me. And become a stigma buster.

Jackie Chan

It‘s not fair that people ignore AIDS in Africa because it‘s Africa. It‘s not fair.

India Arie

The heart of the security agenda is protecting lives - and we now know that the number of people who will die of AIDS in the first decade of the 21st Century will rival the number that died in all the wars in all the decades of the 20th century.

Al Gore

28

HIV / AIDS

I have friends of mine who have died of AIDS and many of those friends…did not tell me until the very end...because they felt that there was a stigma, a taboo, attached to it…now we have more women infected with HIV/AIDS, many of those women were infected by their husbands who did not tell them.

Bianca Jagger

We want the world to focus on children whose lives have been devastated by AIDS. The millions of children who are missing their parents; their childhood, their future but most importantly, they are missing YOU. Everyone can make a real difference. Your voice is needed in a global movement that can change their world.

Pierce Brosnan Let us give publicity to HIV/AIDS and not hide it, because [that is] the only way to make it appear like a normal illness.

Nelson Mandela

AIDS is no longer a death sentence for those who can get the medicines. Now it‘s up to the politicians to create the „comprehensive strategies“ to better treat the disease.

Bill Clinton

HIV / AIDS

29

30

PREVALENCE

31

Since the onset of the epidemic in the 1980s, more than 70 million people have been infected with the virus and about 35 million people have died. Currently about 36.7 million people are living with HIV (World Health Organization, 2016).

32

PREVALENCE

= 1 million deaths

AIDS

Black death + WW1 + Spanish flue + WW2

PREVALENCE

33

Number of people living with HIV globally = 36,7 million / 0,8% (World Health Organization, 2016)

W. & C. Europe & North America

Latin America

Sub-Saharan Africa

2,4 million 6,5%

2 million 5%

25,5 million 70%

34

PREVALENCE

Middle East & North Africa

230 000 0,6%

Asia & Pacific

5,1 million 13,9%

PREVALENCE

East Europe & C. Asia

1,5 million 4%

35

HIV prevalence rate in Sub-Saharan Africa = 4,7% This map shows the estimated percentage of people with HIV in SubSaharan Africa for each state based on best estimates by the World Health Organization and the UN. More than two-thirds (70%) of all people living with HIV (25,5 million), live in sub-Saharan Africa. This includes 91% of the world‘s HIV-positive children. In 2013, an estimated 1,5 million people in the region became newly infected. An estimated 1,1 million adults and children died of AIDS, accounting for 73% of the world‘s AIDS deaths in 2013 (Kaiser Family Foundation, 2016).

Top 10 countries with the highest prevalence rates: 1 Botswana

22,5%

2 South Africa

3 Zimbabwe

19,2%

4 Zambia

13,5%

5 Namibia

13,3%

6 Mozambique

11,5%

7 Malawi

11,0%

8 Uganda

6,5%

9 Kenya

6,3%

10 Tanzania

5,6%

36

PREVALENCE

14,7%

8

9

10

5-10% (4 countries)

7

4

>10% (9 countries) 5

1-5% (32 countries) <1% (67 countries)

6

3 1

2

N/A

(World Health Organization, 2016)

PREVALENCE

37

Exploring HIV in Namibia I chose to investigate the HIV epidemic, focusing on Namibia, which is is a country in southern Africa (marked in red) whose western border is the Atlantic Ocean. It shares land borders with: 1 Zambia 2 Angola 3 Botswana 4 South Africa I am particularly interested in Namibia because I was born there. I have lived in the country for most of my life and have witnessed the vast effects that HIV is having on its economic development. Namibia currently has the 5th highest HIV prevalence rate in the world. With the disease being recorded the leading cause of death since 1996, it has become much more than a health problem for the country. AIDS is a threat to the very fabric of Namibian society, affecting mostly adults in their prime.

38

PREVALENCE

2

1

3

4

PREVALENCE

39

Population and regions of Namibia Namibia is the second least populated country in the world, with only 2.56 people per square kilometer. The current population is estimated at 2,51 million with a rate of about 1,9% annual increase (Countrymeter, 2016).

Namibia is divided into 13 regions and subdivided into 121 constituencies.

The largest city and capital is Windhoek, with a population of about 325,800. This is the only city with a population exceeding 100,000. The next-largest city is Walvis Bay, with about 95,000 people.

This table indicates the different regions with their respective population: 1 Khomas

415 000

2 Ohangwena

255 000

3 Omusati

250 000

4 Kavango

238 000

5 Oshikoto

195 000

6 Oshana

189 000

7 Erongo

182 000

8 Otjozondjupa

154 000

9 Zambezi

99 000

10 Kunene

98 000

11 Hardap

87 000

12 Karas

86 000

13 Omaheke

74 000

40 PREVALENCE

2

3 3

9

6 5

4

8

10

13 7 1

11

12 <300 000 - 450 000 >200 000 - 300 000 >100 000 - 200 000 <100 000

(City Population, 2016)

PREVALENCE

41

The people of Namibia Eventhough Namibia has such a low population count, it has an incredibly diverse culture. There are 12 different major ethnic groups with a large range of tribes among them, and about 30 unique languages are spoken throughout the country (HowAfrica, 2015).

Damara - 7% of the population

Herero - 7% of the population

Himba - 1% of the population

Kavango - 9% of the population

Nama- 5% of the population

Ovambo - 50% of the population

(HowAfrica, 2015)

42

PREVALENCE

San - 3% of the population

Tswana - 1% of the population

Caprivians - 4% of the population

Basters - 0,5% of the population

Coloureds- 1% of the population

Whites - 7% of the population

(HowAfrica, 2015)

PREVALENCE

43

HIV prevalence rate in Namibia = 13,3%

This map shows the estimated percentage of people with HIV in Namibia for each region based on the World Health Organization and the UN. Regions in Namibia with the highest prevalence rates: 1 Zambezi

23,7%

2 Omusati

17,4%

3 Kavango

17,0%

4 Oshana

16,1%

5 Ohangwena

15,6%

6 Oshikoto

13,4%

7 Erongo

12,5%

8 Karas

12,4%

9 Otjozondjupa

12,0%

10 Khomas

11,9%

11 Kunene

9,7%

12 Hardap

8,2%

13 Omaheke

7,3%

(Ministry of Health and Social Services 2013, 210)

44

PREVALENCE

2

44

5 5

1

6

3

11 9

13 7 10

12

<20 - 25%

8

>15 - 20% >10 - 15% <10% (Ministry of Health and Social Services 2013, 210)

PREVALENCE

45

Key affected population Sexual intercourse is by far the most common way to becoming infected (Barnett & Whiteside 2002, 3). In Africa heterosexual sex is the major mode of transmission. The diagram below indicates the distribution of new HIV infections among population groups: 2% People who inject drugs 4% Sex workers 6% Homosexuals 9% Clients of sex workers

79% Rest of the population -Mother to child transmission -Widespread poverty -Unemployment -Lack of knowledge -Violance against women and children -Cultural norms -Lack of mobility and services

(UNAIDS 2016, 9)

46

PREVALENCE

HIV in numbers Latest statistics in Namibia:

Number of people living with HIV

220 000

Women aged 15 and over living with HIV

120 000

Children aged 0 to 14 living with HIV

18 000

Orphans due to AIDS aged 0 to 17

45 000

Deaths due to AIDS

5 100

Population with knowledge about HIV

56%

Condom use with non regular partner

70%

HIV medication coverage

69%

(UNAIDS, 2015)

PREVALENCE

47

48

TREATMENT

49

Currently there is no effective cure for HIV, but with proper treatment and medical care, HIV can be controlled. The medicine used to treat HIV is called anti-retro-viral therapy or ART. Presuming that the ART is taken on time, every day, this medicine can dramatically prolong the lives of many people with HIV, keep them healthy, and greatly lower their chance of transmitting the virus to others. Â A HIV infected person who is treated before the disease is far advanced, and stays on treatment can live nearly as long as someone who does not have HIV (U.S. Department of Health & Human Services, 2016).

50

TREATMENT

TREATMENT

51

Antiretroviral therapy HIV is treated using a combination of medicines to fight HIV infections.

This is called antiretroviral therapy (ART). ART isnâ&#x20AC;&#x2122;t a cure, but it can control the virus so that you can live a longer and healthier life.

It is important for a patient to adhere strictly to an ART regimen to ensure a successful response to treatment and to avoid viral rebound or drug resistance. Research has shown that adherence levels of 95% or higher are required to ensure such success (Paterson et al., 2000).

These medicines prevent the virus from multiplying, reducing the amount of HIV in your body. This gives your immune system a chance to recover and fight off infections and cancers. Even though there is still some HIV in the body, the immune system is strong enough to fight off infections and cancers.

ART not only helps the body to recover from the virus but also reduces the chances of transmission. If an HIV-positive person adheres to an effective antiretroviral therapy regimen, the risk of transmitting the virus to an uninfected sexual partner can be reduced by 96%. This makes HIV treatment a new priority prevention option.

ART is recommended for all people with HIV, regardless of how long theyâ&#x20AC;&#x2122;ve had the virus or how healthy they are. If left untreated, HIV will attack the immune system and eventually progress to AIDS. (AIDS info, 2016)

52

TREATMENT

Without treatment:

HIV virus enters the body as soon as the person gets infected

HIV virus attacks the white blood cells (T-cells)

HIV virus multiplies and starts attacking uninfected T-cells

With Antiretroviral therapy:

HIV virus enters the body as soon as the person gets infected

ART drug ataches itself to T-cells and repells the HIV virus

TREATMENT

T-cell remains uninfected maintaining a strong immune system

53

Life expectancy The World Bank projects that by 2020, the life expectancy in SubSaharan Africa will be 43 due to AIDS, rather than 62 without AIDS (Whiteside 1998, 22). However, Antiretroviral therapy can help HIV patients live longer. In Namibia, people with HIV who start treatment with antiretroviral therapy, have life expectancies of around 80% of that of the general population (67) provided that they start treatment before their CD4 count drops below 200 (cells per microliter). These findings are encouraging and show that with long-term treatment, HIV can be managed as a chronic illness in middle- and low-income settings (ScienceDaily, 2013).

Age 67 A person without HIV

HIV+ Age 54 A person with HIV diagnosed at age 20 taking current HIV medicine

HIV+ Age 32 A person with HIV diagnosed at age 20 not taking current HIV medicine

54

TREATMENT

The effects of Antiretroviral therapy Since the introduction of Antiretroviral therapy many HIV life´s were saved. A 2010 documentary film, called ``The Lazarus effect`` illustrates the transformation effect of life-saving antiretroviral medicine through the stories of HIV+ people in Zambia (The Lazarus Effect, 2010).

By taking the medication in as few as 40 days, the medicine can help bring people back to life. Here is a short story of Concilia Muhau, one of the patients starring in the documentary:

Concillia Muhau is 26 years old. She started ARV therapy in 2004, but when she began to feel better, she stopped taking the drugs. In early 2009, she became very ill. At her worst, she weighed just 29 kg.

“The way I was feeling” she submits mere months later, “It was like I was already dead. ” (Concilia Muhau) In March 2009, Concillia started ARV treatment for a second time (Oprah, 2010).

Now healthy, Concillia recently completed a HIV peer education course at the Kanyama Clinic in Zambia and is a volunteer, educating people about the importance of the adherence to the medication. “Now, I feel like I‘ve been given another chance to be able to take care of my beautiful daughter.“ (Concilia Muhau)

TREATMENT

55

The history of the Antiretroviral therapy In 1995 clinical trials for ARVs were initiated & approved as a standard treatment in the US which saw an immediate decline in deaths.

In Africa however, deaths only declined in 2007 Why the gap?

Drugs were too expensive - $10,000 USD per person per year Why were the drugs so expensive?

The pharmaceutical companies put a patent on the drugs setting prices as high as they wanted because they had exclusive rights.

Thus Africas market for ARVs consisted of just 1% of total revenues.

Meanwhile in Thailand and India, generic companies produced drugs at a reduced price from $10,000 per patient annually, to $365 per patient Because of the rights to exclusivity on ARVs, African countries were not allowed to import cheaper generic drugs from India or Thailand Why not allow countries in Africa to import generic drugs?

Pharmaceutical companies were worried that allowing certain countries to import generic drugs would set a precedent, encouraging other countries, including the United States, to try to do the same. African countries actively protested against those patents, to allow the importation of generics In 2001, after a long fight, the South African government began importing generic drugs into Africa without protest from Western countries, which saw a great decline in deaths Although African countries are now able to import generic ARVs, the problems of affordability and accessibility are far from over. Many other patented drugs remain out of reach for people in developing countries.

(Fire in the Blood, 2013)

56

TREATMENT

Third World (Fire in the Blood, 2013)

TREATMENT

57

People receiving Antiretroviral therapy globally Regardless of all the challenges, new global efforts have resulted in an increase of people receiving HIV treatment in recent years, particularly in resource-poor countries. Since December 2015, 17 million people living with HIV were receiving antiretroviral treatment (ART). This means that 46% of all adults and 49% of all children living with HIV are now accessing ART (Global HIV and AIDS Statistics, 2016).

2000

2005

2010

2011

28,9 million

31,8 million

33,3 million

33,9 million

770 000=2,6%

2,2 million=6,9%

7,5 million=22,5%

9,1 million=26,8%

2012

2013

2014

2015

34,5 million

35,2 million

35,9 million

36,7 million

11 million=31,8%

13 million=36,9%

People living with HIV 58

15 million=41,8%

17 million=46,3%

People receiving treatment TREATMENT

People receiving Antiretroviral therapy in Namibia Since 2000 the coverage of Antiretrovirals has increased immensely. The latest statistics, released by the Ministry of Health and Social Services, reveal that close to 165 000 people are on the medication, which accounts to 69%. Of this figure, about 60% are women.

2000

2005

2010

2011

180 000

180 000

200 000

210 000

0=0%

26 000=7%

90 000=45%

111 300=53%

2012

2013

2014

2015

250 000

260 000

260 000

240 000

161 200=62%

166 400=64%

165 600=69%

145 000=58%

People living with HIV

People receiving treatment TREATMENT

59

Cost of Antiretroviral therapy The estimated cost per patient - year of treatment varies widely across individual patients and country settings. In low-income and lower middle-income countries such as Namibia, the mean cost per patientyear of treatment is $642 (PEPFAR, 2013).

This estimated total represents the full cost of providing ART and supportive services and includes all resources required to provide comprehensive treatment at and above the site level. These include: - Antiretroviral drugs (ARVs) for patient treatment - Non-ARV recurrent costs such as:

- Clinical staff salaries and benefits

- Laboratory and clinical supplies

- Non-ARV drugs for opportunistic infections

- Building utilities

- Travel

- Contracted services - Investment costs such as:

- ARV buffer stock (inventory) to support a reliable supply chain

- Building renovation & construction

- Laboratory and clinical equipment

- In-service training of ART providers - Program management and central support costs

1 Year 365 days

60

$642 = N$9260

TREATMENT

Supply of Antiretroviral therapy Since the manufacture of generic antiretroviral drugs, Namibia has mainly received their medical supply from Asian pharmaceutical companies such as India and Thailand. However, since the beginning of 2016, Minister of Health and Social Services, Dr Bernard Haufiku said that “the government would be purchasing ARVs from Uganda from now on, as they are cheaper compared to Asian countries.“ (New Era, 2016).

In April 2016, Namibia received the shipping of 70 tonnes of anti-retroviral medicines worth $4 million by Uganda’s Cipla Quality Chemicals Ltd, which accounts for the single largest export order for an East African pharmaceutical company.

Uganda Quality Chemical Industries

Kampala Namibia

Map of Uganda

Map of Africa

TREATMENT

61

Funding organisations Namibia receives funding from various countries but the bulk of the donor funds comes from the United States government. The two main sources of international funds for ART in Namibia are the United States President’s Emergency Fund for AIDS Relief (PEPFAR) and the international Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund).

U.S. President´s Emergency Plan for AIDS Relief

The President‘s Emergency Plan For AIDS Relief is a United States governmental initiative to address the global HIV/AIDS epidemic and help save the lives of those suffering from the disease, primarily in Africa.

PEPFAR works to jointly plan, implement and monitor US - Namibia co-investments to achieve epidemic control and foster a sustainable response.

To Fight AIDS, Tuberculosis and Malaria Founded in 2002, the Global Fund (GF) is a partnership between governments, civil society, the private sector and people affected by the diseases. The Global Fund raises and invests nearly US$4 billion a year to support programs run by local experts in countries and communities most in need and has contributed significantly to the costs of antiretroviral medication and laboratory costs,

62

TREATMENT

Namibian HIV / AIDS expenditures In comparison to other countries in Sub-Saharan Africa, Namibia´s health budget is the second highest after South Africa (Ministry of Health and Social Services 2010, 11). Taking reference from Namibias budget statement, over 27% of the countries national budget is granted for the health sector. Of that amount the government contributes 64% to the HIV budget (Ministry of Health and Social Services 2015, 29).

The list below shows the latest expenditures by all the funding sources: Sources:

Amount:

Central Government

N$ 136,620,606

64%

PEPFAR

N$ 57,658,447

27%

Global Fund

N$ 11,978,348

6%

GIZ

N$ 1,675,746

1%

UN Agencies

N$ 2,448,193

1%

Private Sector

N$ 2,442,655

1%

Other International

N$ 522,634

Total

N$ 213,346,629

Government 64%

PEPFAR 27%

Global Fund 6%

TREATMENT

Percentage

0,2%

Rest 3%

63

Barriers keeping patients away from medication Eventhough Antiretroviral medication is readily available in Namibia only 69% of the people, eligible for the treatment were reported to have received the medication. A recent survey identifies access barriers to ART for HIV-positive patients and their relevance in Namibia. The findings provide evidence that more tailored interventions have to be introduced to increase ART-uptake (Seeling et al. 2014, 268-275).

Fear of stigma and discrimination Staff shortage Lack of adequate counseling space High staff turnover Inadequate training for staff Lack of knowledge of patients Fear of indirect treatment costs Religious issues Inadequate communication skills Accessibility of HIV services Availability of antiretroviral drugs

Very important barrier

64

Important barrier

TREATMENT

Not so important

Factors for low medication adherence In a similar survey, health workers were asked about what factors they thought made it difficult for their patients to attain high levels of ART adherence. These responses were categorised under the following themes: forgetfulness, difficulty accessing the hospital, poverty issues, alcohol and drug abuse, unexpected events, stigma, instructions and lack of support (Ministry of Health and Social Services 2013, 31).

30%

Difficulty accessing hospital 19%

Not understanding instructions Poverty

11%

Alcohol and drug abuse

11%

Unexpected events

10%

Sigma No community or family support

8% 6%

Forgetfulness

3%

Others

2%

The findings reveal that 30% of patients found it hard to attain high adherence to ART due to to difficulty accessing the hospital. Responses in this theme included the following: “There being long distances to the health facility”; “Patients having no transport”; “The cost of transport being high”.

TREATMENT

65

66

PATIENT NEEDS

67

Besides the effective Antiretroviral therapy, a HIV positive patient has many more needs in order to cope with the virus. HIV/AIDS is often associated with a range of psychosocial weight that must be addressed throughout all stages of the infection. Psychological support is therefore critical for helping individuals, couples, and families affected by HIV to cope with their emotions and psychosocial needs.

68

PATIENT NEEDS

PATIENT NEEDS

69

Psychosocial impacts of an HIV diagnosis Newly diagnosed HIV-infected patients may have little knowledge or a distorted picture about the HIV disease. A commonly held belief, especially in the pre-Antiretroviral era, is that one would have to give up any plans for the future and live in ill health for the rest of the days to come (Iris WS Chan, Rita WY Chung, 2007).

As soon as patients get diagnosed HIV positive, they would show a variety of different reactions. The most common responses include:

shock

disbelief

anger

denial

fear

anxiety

depression

guilt

70

PATIENT NEEDS

PATIENT NEEDS

71

Steps to follow once infected with the virus People diagnosed with the virus should follow strict steps in order to live a healthy and long life:

Step 1: See a health care provider Prompt medical care and treatment with HIV drugs as soon as possible is the best way to stay healthy.

People with HIV should work closely with their health care providers to decide what HIV medicines to take.

Step 2: Get a HIV baseline evaluation This evaluation includes all the information collected during a person´s initial visits with a health care provider. It includes a review of the person´s health and medical history, a physical exam, and lab tests.

Step 3: Start with a HIV regime A HIV regime is a structured treatment plan designed to improve and maintain the health, which usually consists of a combination of antiretroviral drugs.

Step 4: Find support Talk with others who have been diagnosed with HIV and AIDS and ask doctors if they know of any support groups.

72

PATIENT NEEDS

Step 5: Tell others Deciding to tell others that you are HIV positive is an important personal choice. It can make a big difference in how you cope with the disease. .

Step 6: Monitor your health Once you have been diagnosed with HIV, you need to pay closer attention to your health than you did before. Maintain a healthy lifestyle such as good nutrition, exercise, control of recreational substance

Step 7: Go for regular tests and counseling Make sure that the virus has not reactivated the blood cells, by having picked up a new infection or by having missed a few doses of the medication. .

Step 8: Move forward with your life Life does not end with a diagnosis of HIV. In fact, with proper treatment, people with HIV usually live long healthy lives. .

PATIENT NEEDS

73

The story of Veronica Kalambi Written by Kaula Nhongo on 05 December 2014 FINDING out that she was HIV positive 12 years ago came as such a big blow. Thoughts of death filled her mind on a daily basis. From the death thoughts, she went through the denial phase where she managed to convince herself that the doctors had made a mistake. She shied away from people; pushing away her closest friends because of fear that they would discover the secret that she vowed would die with her. For years, Veronica Kalambi struggled with accepting her HIV status and making the move towards living positively.

“How could I learn how to live with it when I was not even prepared to accept it? When I went to have myself tested it was only because my friend was doing it, and so I was not hundred percent prepared.”

Veronica was only 26-years-old when she tested positive. Back then having HIV/Aids was something that people did not discuss openly because they were afraid of stigmatisation. For five years, Veronica not only lived with the fear of dying but also the secret that she was HIV positive. Not telling people also meant that she could not follow the procedures necessary to control the virus. Advice from counsellors to have her CD4 count checked fell on deaf ears because she had lost all hope of living and therefore did not see the need for it. In her head she considered herself dead already. Her intimate relationship suffered because she also kept her status from her partner, which put a strain on their relationship and he left. Losing her support system made everything worse and she started wasting away until the time when she met another HIV patient – a woman who opened her eyes to the truth and the benefits of disclosing her status.

In 2010, she became a volunteer at AIDS Care Trust where she received more information on how to live with the virus. Becoming a volunteer motivated her to open up, because she knew that she would be able to move people more if she spoke from experience. From volunteering at the NGO, Veronica also found the motivation to have her CD4 count checked and she was put on treatment.

“I am glad that I am now on medication because before I always feared that by taking the medication people would find out about my status since you have to take them every day,” she says.

Through her story and experiences, Veronica now works as a Project Officer for Namibia Women’s Health Network helping other women who are going through what she went through (Windhoek Observer, 2014).

74

PATIENT NEEDS

â&#x20AC;&#x153;The biggest problem was, when I started to isolate myself from family and friends. It affected my health negatively because I was thinking I do not deserve to be around them and what will be their reaction towards me if I disclosed my status to them.â&#x20AC;?

PATIENT NEEDS

75

Interview with former nurse, Adonia Wienecke 1.For how long have you worked in the field of nursing?

I started training as a nurse in 1973 and retired in 2013.

2.How many years have you dealt with HIV positive patients?

1992-2001: Professional nurse in charge of the Screening & STD/HIV clinic 3.What can you tell me about the behaviour of HIV positive patients?

People living with HIV and AIDS express different types of behaviour, depending on the reasons for testing.

They are mostly shocked and angry. After that the period of denial and disbelief begins. Post counselling sessionâ&#x20AC;&#x2122;s result in changes and acceptance sets in. This can take months of continuous counselling.

4.What were you´re duties working with these patients?

Physical examinations; counselling; treatment of opportunistic conditions and referrals to doctors for problems outside my scope of practice.

5.What skill do you consider is the most important in this position?

An empathetic persons; good listening and communication skills; verbal and non-verbal. Understanding the human behaviour during illness/ sickness and the ability to care for people.

6.What do you think hinders people from getting tested for HIV? Fear of the unknown; death; shame; mistrust.

HIV is a sexually transmitted disease. Sex is still a taboo topic and people find it difficult to relate to it. People do not believe that medical staff will adhere to the confidentiality aspect of the treatment program.

7.Besides Antiretroviral therapy, what else do these patients need?

Information and understanding about the spread; reinfection; diet; rest and a positive lifestyle. Counselling and the use of support groups is also essential.

76

PATIENT NEEDS

8.Do you have any suggestions for making it easier for HIV patients to get follow up care and support?

Quality of education of health workers especially in their attitudes towards the people living with HIV and AIDS. Also educating the patients about the disease and the importance of using the facilities available. Centres should be conducive for caring and privacy and they should have friendly personnel. Furthermore, centres should be in reach of patients and should be a multipurpose institution.

They should not be exclusive for HIV/ AIDS as this may create feelings of isolation and discrimination and will cause more stigmatisation.

9.What would you like to see improve in the field of HIV services in Namibia and what programmes would you suggest?

Education is the key in managing and improving the services. Education of sexual health should start in the schools, universities and sport; newspapers and at home to prevent the contracting and spread of the disease. Furthermore, mobile clinics should be introduced in order to reach and to bring the services close to homes.

1st of December is World AIDS Day. That is not enough. Regular programs should be done by: TV – more programs, information pertaining to statistics, treatment, latest interventions like vaccinations; Sports – fun runs, billboards, T-shirts; Private sector – sponsor programs and donations for voluntary workers; Social media – facebook, twitter in terms of information on HIV/AIDS. (Wienecke, 2016).

PATIENT NEEDS

77

78

HIV SERVICES

79

Hospitals play a critical role in the delivery of HIV services, such as counselling, care and support, treatment, testing and the supply of medication. However, since the rise in HIV prevalence, the epidemic has put substantial pressure on an already strained health system. HIVpositive patients burden healthcare facilities and prevent access to care for other patients. Up to 55% of patients admitted into hospital can be HIV-positive.

Hospitals are thus often overcrowded and patients have to wait hours in line before being attended to. Furthermore the roll out of HIV medication has put increased pressure on these facilities in terms of staff, storage space and laboratory capacity which is being constrained due to a shortage of buildings.

80

HIV SERVICES

HIV SERVICES

81

Types of HIV facilities The following illustrations depict the various health services found in Namibia: Hospitals A hospital is typically the major health care facility in its region, with large numbers of beds for intensive care and additional beds for patients who need long-term care.Currently Namibia has 47 hospitals throughout its 13 regions.

Health centers Health centers are a network of clinics staffed by a group of general practitioners and nurses providing healthcare services to people in a certain area. These centers are a lot smaller than hospitals but still provide a vast variety of services. Namibia has a total of 37 Health centers.

Clinics Clinics typically cover the primary healthcare needs of populations in local communities, in contrast to larger hospitals which offer specialised treatment.

Altogether Namibia has about 248 clinics operated by the Ministry of Health and Social Services.

82

HIV SERVICES

Sick Bays A sick bay is a section of another organisation, such as a school or college used for medical purposes. These facilities are periodically visited by health workers to provide services. Many times these sick bays are facilitated in containers for their mobility.

Free standing VCTĹ&#x203A; HIV interventions that include both voluntary pre-and posttest counselling and voluntary HIV testing. People, of their own free will, opt for VCT, which provides them to explore and understand their HIV risks.

These interventions often take place in temporary structures such as tents and relocate frequently.

Mobile clinics Mobile clinics have a critical role to play in providing highquality, low-cost care to vulnerable populations that are living in remote areas.

Depending on the routes they have to cover they need to be quite big and powerful.

HIV SERVICES

83

Availability of HIV services in the health facilities The availability of HIV/AIDS services varies widely throughout Namibia.

Almost all (98%) health facilities in Namibia have an HIV testing system.

Nine in ten health care facilities in Namibia provide some care and support services for HIV. Most (81%) health facilities offer post-exposure prophy-laxis for health facility staff. 75% of facilities report that they provide PMTCT services. Other HIV-related health services are less widely available. Only 18% of facilities offer antiretroviral therapy (ART), which means they prescribe ART and/or provide medical followup services. Overall, HIV/AIDS services are more likely to be available in hospitals and health centres than in clinics or sick bays (Ministry of Health and Social Services 2009, 4).

Hospitals 100 100

Health centers

98

98

Clinics

98

93 88 78 67

69

36

8

HIV Testing System

84

Care and supports services

HIV SERVICES

ART - prescribe and/or provide follow up

Sick bays

Free standing VCT (Voluntary counseling & testing)

96 91

91

80 73

PMTCT - Preventing Mother-to-Child transmission of HIV

89 77

80

Post-exposure Prophylaxis

HIV SERVICES

85

What are the challenges?

Geographical accessibility

nd Dema

ly Supp Lack of health facilities

Shortage of skilled health workers

Distribution and storage of ART medication

Lack of transport to health facilities

Fear of stigma and discrimination

Deficiency of knowledge concerning the virus and the treatment

86

HIV SERVICES

What are the objectives?

Launch mobile clinics to reach remote areas throughout the country

Develop new infrastructure specializing in HIV

Demand

Supply

Provide training facilities to promote and foster health education

Supply ART from all health facilities

Introduce a new transportation service to all health facilities

Initiate support groups

Launch awareness campaigns and educational programmes

HIV SERVICES

87

88

LOCATION

89

Location Altogether, Namibia has 248 clinics, 37 health centres and 47 hospitals, most being in the larger cities and towns. Some clinics and health centres also have outreach points where health workers periodically visit to provide services. As a result 80% of the population now lives within 10km of a clinic. This still leaves 20% or over 300 000 people in remote areas, without ready access to health services (MCA-N, 2015).

I want to focus on these remote areas, targeting people that live in rural communities. As this adresses the whole country, I will identify several sites which are spread throughout Namibias 13 regions.

90

LOCATION

LOCATION

91

Target areas

Khomas region

Kunene region

Kavango region

Otjozandjupa region

92

LOCATION

Zambezi region

Omaheke region

Hardap region

Karas region

LOCATION

93

Cities = Hospitals This diagram displays all the cities in Namibia. Each of them are equipped with at least one hospital, with most of them offering a full range of HIV services.

94

LOCATION

Towns = No hospitals All the red dots indicate the smaller towns throughout Namibia (6000 -25000 inhabitants). None of them are providing a hospital but they are equipped with at least one primary health care facilitiy such as a health center or a clinic, covering only some of the basic needs for HIV patients.

LOCATION

95

Settlements = No health facilities The red dots reveal all the small settlements and remote places througout the country (20-2000 inhabitants).

None of them supply permanent HIV services and only offer temporary testing stations or sick bays.

96

LOCATION

Identified zone The red zone highlights the areas which are mostly populated with smaller towns and settlements. These regions are lacking the HIV services needed, and are thus most vulnerable to new infections.

LOCATION

97

Roads within the identified zone This diagram presents the road network across the country, showing the primary circulation in red, the secondary circulation in black and the tertiary road network in light red. The study aims to locate the existing connections within the identified zone.

98

LOCATION

Placement of new interventions Proposed locations for the newly proposed structures are identified within the highlighted zone and are filling the voids where there´s no hospitals. The exact placement is based on the closest town or village, which offer sufficient infrastructure.

LOCATION

99

Chosen sites and their regions All of the 11 sites are placed within an existing matrix of infrastructure, covering all the regions in the country. The central hub will be located in the capital - Windhoek and the ten modules will be placed in the following towns:

3

4

6

2

5

7

1

8 9

10 11

100

LOCATION

1

Windhoek Central hub - Region: Khomas - Population: 415 000

2

Kamanjab Module 1 - Region: Kunene - Population: 6 012

3

Okongwati Module 2 - Region: Kunene - Population: 5 078

4

Mpungu Module 3 - Region: Kavango - Population: 18 332

5

Tsumkwe Module 4 - Region: Otjozondjupa - Population: 10 200

6

Kongola Module 5 - Region: Zambezi - Population: 5 600

7

Otjinene Module 6 - Region: Omaheke - Population: 3 400

8

Aranos Module 7 - Region: Hardap - Population: 3 683

9

Maltahรถhe Module 8 - Region: Hardap - Population: 6 000

10

Bethanien Module 9 - Region: Karas - Population: 2 000

11

Aroab Module 10 - Region: Karas - Population: 5 000

LOCATION

101

Windhoek This diagram shows the map of Windhoek, which is located in the Khomas Highland plateau area, at around 1,700 metres above sea level, almost exactly at the countryâ&#x20AC;&#x2DC;s geographical centre.

102

LOCATION

Finding the site The factors that influenced the site choice were accessibility, exposure, closeness to a hospital, size of site, views, fairly flat geography as well as being close to the poverty strickened communities.

Poverty strickened

Connecting Windhoek to northern regions of Namibia

Wealthy

Poverty strickened

Existing hospitals Highway cutting through the city Main road connecting the East to the West

Wealthy

Most accessible point Target areas Connecting Windhoek to southern regions of Namibia LOCATION

103

Location of the central hub This diagram shows the map of Windhoek. The grey circle identifies the site location for the central hub

104

LOCATION

Zooming into the site This image zooms into the proposed site which is hatched in green. The site runs along the highway passing through the city.

N

LOCATION

105

Site Analysis Site - This diagram illustrates the extend of the chosen site. Its shear size allows for a lot of flexibility and a possibility to engage with the nature.

190 000 m2

Points of interest - There are several attractions surrounding the site such as the Katutura Hospital, the Red Cross society, a parish, a gas station and a shopping mall

106

LOCATION

Figure Ground - The density plan reveals the built mass within the area.

The result shows a lot more open spaces than built spaces.

Softscape - This diagram depicts the open and vacant spaces surrounding the site.

LOCATION

107

Site Analysis Circulation - The site sits right next to the major intersection of the Western bypass highway and the Independence Avenue.

Topography - The chosen site sits on a 12 meter high hill which has a gentle slope towards the West and a steep fall towards the East.

108

LOCATION

Views - As the site is elevated it amplifies beautiful views out towards the Eros mountains in the far East.

Climate - The summer solstice lies at an angle of 71째 and in winter at 39째. The prevailing wind comes from the East.

N

39째

71째

LOCATION

109

Site Analysis Residential - The black hatches identify all the residential buildings which are predominantly found on the West of the site.

Commercial - Here the fills indicate all the commercial use buildings within the area, including shops, businesses and office spaces.

110

LOCATION

Industrial - This is showing all the industrial land use, which is found East of the highway, marking the northern industrial area of Windhoek.

Institutional - The following marks identify the Katutura Hospital (one of Namibias biggest hospitals), the Red Cross Society and several schools.

LOCATION

111

Site Photos

1

2

3 4

112

LOCATION

View 1

View 2

View 3

View 4

LOCATION

113

114

PROGRAMME

115

The proposal will consist of 11 new facilities, composed of 1 central hub and 10 smaller modules.

Central hub The central hub will be located in the heart of Namibia, in the capital of Windhoek city. This facility will seek to provide comprehensive and quality treatment, counselling, education, prevention campaigns, testing as well as care and support for those already infected by HIV/ AIDS and the ones that are at risk. The building will contain a laboratory, sufficient counselling space, examination rooms as well as a big storage space for all the medication and vaccines.

Seeing that there is a great shortage of qualified health workers in the public sector, this intervention will also offer educational programmes and training facilities to promote and foster existing as well as new health care workers and volunteers.

All in all the central hub will serve as a supplier to all the smaller modules, providing them with qualified health staff, medication and maintenance support.

Modules Each of the modules will be quite a bit smaller in size and functions compared to the central hub but they will retain the core services, which consists of spaces for treatment, counselling, care and testing, as well as accommodating staff members. These units will primarily focus on reaching out to rural communities. Each unit will be equipped with several mobile clinics, covering identified areas within the country. The whole masterplan will thus work as a site network, containing small integral parts that work together in order to try and reach everyone in need.

116

PROGRAMME

Supply of medication and health staff

Sending mobile clinics to rural communities

PROGRAMME

117

Branding of the buildings In order to draw as many patients as possible to the proposed buildings, the branding and their program becomes very important. HIV patients will not want to visit the institutions if they are called “HIV/AIDS clinics“.

Rather than focusing exclusively on HIV/AIDS these facilities should allow for a broader program, inviting a diversity of patients .

Branding the facilities as the “Center for disease control and prevention“, will merge HIV services with others, thereby drawing more patients to the building and at the same time disguising the HIV stigma.

Namibian Centers for Disease Control and Prevention

HIV/AIDS Clinic

118

PROGRAMME

Centers for Disease Control and Prevention The Centers for Disease Control and Prevention (CDC) is the leading national public health institute of the United States. The CDC is a United States federal agency under the Department of Health and Human Services, headquartered near Atlanta, Georgia.

Its main goal is to protect public health and safety through the control and prevention of disease, injury, and disability in the US and internationally.

Since 2002, CDC has helped Namibia develop and implement HIV/AIDS prevention, care, and treatment programs. CDC-Namibia helps build the capacity of the countryâ&#x20AC;&#x2122;s healthcare workforce. CDCâ&#x20AC;&#x2122;s assistance has strengthened national efforts to prevent HIV transmission and to expand care and treatment services. The aim of all support is to ensure that Namibia soon sees an AIDS-free generation.

PROGRAMME

119

Most severe diseases in Namibia There are 357 generic infectious diseases in the world today. 211 of these are endemic, or potentially endemic to Namibia. Here is a list of the most severe diseases that need attention within the country: 1

HIV/AIDS

2

Tuberculosis

3

Malaria

4

Hepatitis A

5

Typhoid fever

6

Hepatitis B

7

Rabies

8

Yellow fever

9

Measles-mumps-rubella

10 Chicken pox 11 Flu 11 Lower Respiratory Infections 12 Diarrhoeal diseases 13 Diabetes 14 Meningitis 15 Pneumonia

120

PROGRAMME

PROGRAMME

121

Services provided The following diagrams illustrate the services that will be provided and advertised by the new proposed health centers:

Free testing and diagnosis

Counseling

Family planning

Health education 122

PROGRAMME

Pharmaceutical care

Nutrition counseling

Lab testing

Vaccinations PROGRAMME

123

Entrance

Space Program for the central hub

Security

Office Pharmacy Administration

Toilets

Info

Medical stock Reception Registration & Monitoring Clinic

Examination Rooms

Laboratory

Health care Group Counselling

Pre-and post Counselling Rooms

Medical Equipment

Garages/ Delivery

Cleaners Storage

Generator

Medical Records

Refuse 124

PROGRAMME

Waiting Area

Family Planning

Toilets

Nutrition Couns.

Contemplation area

Services

GP Offices

Fitness Instructor

Fitness Studio/ Pool

Outside seating

Health Education Outdoor Amphitheater Toilets

Kitchen Visitors Cafe Library/ Resource Center Classrooms Lecture Hall

Kitchen/ Scullery/ Pantry Dining Toilets

Legend

Lockers and changing rooms House keeping Staff Room

Canteen

Dark spaces Staff

Light spaces Interconnected

Bathrooms

Public Staff sleeping quarters

Semi private Private Health facilities

PROGRAMME

125

Entrance

Space Program for all the modules

Security

Office Pharmacy Administration

Toilets

Info

Medical stock Reception Registration & Monitoring Clinic

Examination Rooms

Laboratory

Health care Group Counselling

Pre-and post Counselling Rooms

Medical Equipment

Garages/ Delivery

Cleaners Storage

Generator

Medical Records

Refuse 126

PROGRAMME

Waiting Area

Family Planning

Toilets

Nutrition Couns.

Contemplation area

Services

GP Offices

Fitness Instructor

Fitness Studio/ Pool

Outside seating

Kitchen/ Scullery/ Pantry Dining Toilets

Legend

Lockers and changing rooms House keeping Staff Room

Canteen

Dark spaces Staff

Light spaces Interconnected

Bathrooms

Public Staff sleeping quarters

Semi private Private Health facilities

PROGRAMME

127

Spatial and functional characteristics This diagram gives a more detailed description of all the health care services within the faciliity:

Ticket boxes

Reception Registration & Monitoring

Pharmacy

Outside seating

Testing/ Scanning Storage Toilets

Waiting Area

Medical Records Collection & info counter Pre-and post Counselling Rooms

Contemplation area

Family Planning

Clinic Group Counselling

Chapel

GP Offices

Examination Rooms

Toilets

Laboratory

Fitness Instructor

Dietitian Office Medical Records

128

Medical Equipment

Fitness Studio/ Pool

PROGRAMME

Function: Before entering the building, visitors will be welcomed by an outdoor foyer and amphitheater, which allows for plenty of seating possibilities and shaded spots. This space will act as a buffer before proceeding to the registration and monitoring units, placed at the entrance of the building. Parts of this space could be used for events and functions.

Characteristics: This area should be open for the public and well landscaped to create harmony with the surrounding context.

Size and fittings: One big open space with a lot of trees, rocks, benches and lights Function: Patients must be identified, monitored, visit registers completed, and patient medical records folders retrieved and prepared (patient card/ID is opened). In addition, a simple symptom checklist should be conducted, focusing on the presence/absence of cough or new symptoms or illness to determine fast track procedures.

Characeristics: This space should be right at the entrance of the building and close to the waiting area, privacy should dictate, records and registers should be kept in locked filing cabinets or shelves in a room that can be locked.

Size and fittings: Provide several booths next to each other with desk space and two chairs, filing cabinets and storage.

Function: Patients that need certain medicines, vaccines, examination or psychological help will need to wait in line. The space should provide comfort and a rational layout that links it to the services. Coughing patients with known or suspected TB should be separated and triaged for rapid evaluation to minimize their time waiting in crowded areas. Further, access to toilet and hand washing facilities should be in close vacinity as well as a play area for children. Patient education materials should be provided in waiting areas to enhance the patientsâ&#x20AC;&#x2122; knowledge and skills and to minimize boredom.

Characteristics: These areas should be for all visitors, to avoid stigma. The space should be well-ventilated to control measures needed to minimize transmission of tuberculosis. If the climate permits, covered outdoor waiting space is preferred to enclosed indoor areas, include landscape and plants.

Size and fittings: One big open roofed space with benches, educational displays, condom dispenser, water dispenser Function: The pharmacy will provide an open plan display of medication for self selection.

These medications can be bought over the counter.

Characteristics: The space should be light, public, well ventilated and allow for minimized movement for customers.

Size and fittings: One open plan space with display shelves and a chashier counter.

(World Health Organization, 2008)

PROGRAMME

129

Spatial and functional characteristics This diagram gives a more detailed description of all the health care services within the faciliity:

Ticket boxes

Reception Registration & Monitoring

Pharmacy

Outside seating

Security

Testing/ Scanning Storage Toilets

Waiting Area

Medical Records Collection & info counter Pre-and post Counselling Rooms

Contemplation area

Family Planning

Clinic Group Counselling

Chapel

GP Offices

Examination Rooms

Toilets

Laboratory

Fitness Instructor

Dietitian Office Medical Records

130

Medical Equipment

Fitness Studio/ Pool

PROGRAMME

Function: The collection and info counter will cater for prescription medication and guidance for patients. This area should have restricted access, especially for areas where narcotics and expensive items are kept. Inside there should be an additional secured area where narcotics and expensive items such as antiretroviral (ARV) medicines are kept. In addition this area will contain a counter space, a display area, an office as well as a big storage room. This space needs to be close to the garages and delivery area.

Characteristics: Private, controlled temperature for the storage of drugs, controlled light as not too much sunlight is allowed to enter this space, secure space from inside and outside.

Size and fittings: Small intimate public interface and a big open storage room with shelves and a sink.

Function: The counselling rooms can be shared and should thus be flexible. The space is most useful located next to the clinical examination rooms. Space is required to support both group and individual pre-test information and post-test counselling.

Characteristics: The space can be less formal and only requires a room for at least 3 people, protect privacy and confidentiality by good positioning within the facility, discreet signs, visual and auditory privacy. Light coloured walls as they are associated with positive emotions (Pressley & Heesacker, 2001). Natural light as it can support self disclosure, reduce the risk of depression and creates a more favourable impression of the counsellor, (Miwa& Hanyu, 2006; Pressley & Heesacker, 2001). Introduce nature, as it can increase comfort, mood levels, and overall attractiveness of office environments (Larsen, Adams, Deal, Kweon, & Tyler,1998).

Size and fittings: 4-5 rooms with a minimum space of 3x3 meters. Not too small “claustrophobic feeling” and not too big as they create “insecurity”. Each room should be equipped with a desk, a few chairs, storage cabinets, a black board, wash hand basin, patient information materials Function: Experience shows that facility-based patient education and patient support groups can be highly effective means for providing pre-test information, support adherence, decreasing stigma, and transferring important ‘positive living’ skills.

Characteristics: Big room dividable into smaller units, visual & auditory privacy, well ventilated, close to counselling rooms, flexible seating, connect to nature, warm and comfortable, avoid cold clinical atmosphere, calming environment, distractions should be limited Size and fittings: 1 big space for 20–50 people, the room should be equipped with loose furniture items to allow for flexibility Function: The space for contemplation should be an outside enclosed area, where patients can process their emotions and find guidance and psychological help if needed.

Characteristics: This space should be a landscaped outdoor platform. It must be big in order to create privacy amongst visitors and have a close connection to nature.

Size and fittings: 1 big landscaped terrain, fitted with benches, pathways, lights, small shaded spots, hubs, trees and shrubs.

(World Health Organization, 2008) PROGRAMME

131

Spatial and functional characteristics This diagram gives a more detailed description of all the health care services within the faciliity:

Ticket boxes

Reception Registration & Monitoring

Pharmacy

Outside seating

Security

Testing/ Scanning Storage Toilets

Waiting Area

Medical Records Collection & info counter Pre-and post Counselling Rooms

Contemplation area

Family Planning

Clinic Group Counselling

Chapel

GP Offices

Examination Rooms

Toilets

Laboratory

Fitness Instructor

Dietitian Office Medical Records

132

Medical Equipment

Fitness Studio/ Pool

PROGRAMME

Function: In these rooms patients receive vaccinations and get examined for HIV. Most national guidelines recommend that patients with early HIV disease (‘pre-ART’) return for clinical assessments every 3 to 4 months, and that patients with advanced disease and those on ART return monthly until stabilized on treatment; then after that, every 3 months.

Characteristics: Positioned close to the counselling rooms, visual and auditory privacy, views out to nature, avoid clinical feel, bring in a lot of natural light, well ventilated Size and fittings: 4-5 rooms with minimum space of 3x3 meters. A single clinical consultation room, fully staffed and dedicated to HIV services five days a week, can accommodate roughly 125–150 patient visits/week. The room should include a sink, a toilet for urine collection and a worksurface for rapid testing Function: Offices for the general practioners will serve to treat acute and chronic illnesses and provide preventive care and health education to patients.

Characteristics: These offices will consist of simple small rooms, closed off to the public with visual & auditory privacy, well ventilated, close to the examination rooms and toilets, flexible seating, connect to nature, warm and comfortable, avoid cold clinical atmosphere, calming environment, distractions should be limited.

Size and fittings: Two small rooms with a minimum space of 4x4 meters. Each room should be equipped with a desk, 3 chairs, an examination table and sufficient storage for the basic medical equipment.

Function: Specialists will collect specimens from patients and perform tests to gain more clarity and knowledge about the sickness. Essential lab services are the minimum lab tests that should be done to offer comprehensive HIV services. These are: HIV diagnostics, Haematology, Venous whole blood collection and send-out for CD4 cell absolute count and for percentage, Blood sugar, TB diagnostics, Malaria diagnostics, Syphilis diagnostics, Pregnancy test etc.

Characteristics: Clean, organised, clinical, should only be accessible by certain health staff, visual privacy from other departments in the building, close to clinical examination rooms Size and fittings: Large enough for all the equipment and staff required for the services.

Function: Once patients have been diagnosed with HIV, they need to pay closer attention to their health. Good nutrition and exercise is thus important. The fitness studio will instruct patients on certain exercise routines and help AIDS patients regain their body strength. Furthermore the Studio will serve as an exercise platform for staff and students.

Characteristics: Open and light double volume space with internal pool and seperate smaller units for private sessions with patients. There should be a close connection to views & nature.

Size and fittings: The studio should be spacious and equipped with sufficient machines and weights. There must be at least one office for a fitness instructor and a receptionist.

(World Health Organization, 2008)

PROGRAMME

133

Journey through the facility This illustration tells a story, describing the journey of a patient visiting the newly proposed centre for an HIV test:

157990

Regis tratio n

“Here is your patient card“

Ticke t

“Lets get you registered! First I need some information on your medical history?“

“I´m afraid your test result is positive“

Free HIV testing

Counselling

Baseline evaluation “We will put you on an HIV regime. I would advice you to enroll in our support groups“

“I will support you and together we will get you through this! You are going to be ok! I promise!“

Group counselling “You will need to come for regular tests and counselling.

This is very important!“

Sp ac ef or co nte mp lat ion

ne alo be

134

PROGRAMME

NEXT: 157990

INFECTION CONTROL

“Number 157990, please proceed to the counter.“

ng elli uns co Pre

“Have you had any severe coughing in the past two weeks?“

to eed c o , pr ea If no ting ar i wa

For me over dic t atio he co un n ter

ht to traig m go s oo If Yes ination r exam

Pharmacy

tion Examina

Laboratory

home

Home

Pharm acy I need to process this

“Here is my prescription“ “I need someone to talk to!!!“

see a psychologist

“These are the pills. The instructions are .........“ PROGRAMME

135

Strategies to break the stigma The following illustrations explain various approaches how to prevent stigmatisation within and outside the building:

Signage HIV clinic

Family care clinic

Signage that is discreet, as well as clear and helpful. Patients are more likely to attend a facility labelled “family care clinic“ than one labelled “HIV/AIDS clinic“

Function of the building HIV+

HIV+

The buildingś function should not be exclusively designed for HIV/AIDS. Introduce another attraction and use to the centre.

This will draw people in, that are not infected with the virus.

One Entrance and one exit Entrance Exit

By introducing only one entrance and exit point you avoid any seperation between visitors, customers and patients.

Communal rooms HIV+ HIV-

136

One pharmacy, one waiting area and one register. The use of a separate public areas for patients with HIV can run the risk that their HIV status may be disclosed in an involuntary manner.

PROGRAMME

Visual and auditory privacy Visual and auditory privacy - Rooms specific for HIV patients should be screened and sound proof to achieve complete privacy and comfort.

Secure medical records Medical records to be secured (visually, auditory & physically) to minimize accidental or involuntary disclosure of HIV infection.

Colour-coding or obvious marks that designate HIV status on patient-held records

Room sizes Avoid spaces that are too big as they tend to create insecurity among patients. Introduce light partitions, screens or landscaping to break up the room and to create more intimate spaces where patients can´t be seen from every angle.

Confidentiality zoning Keep patients and customers a certain distance away from each other to avoid clustering of people thereby making visitors feel more comfortable.

PROGRAMME

137

Spatial intentions The following diagrams illustrate spatial characters that I would like to integrate into the facilities:

Multipurpose facility Introduce several functions to the buildings, instead of making it exclusive for HIV/AIDS. In this way stigmatisation and discrimination can be avoided and more people can be drawn to the facility.

Public and private The facilities should provide privacy to its patients and ensure that a personâ&#x20AC;&#x2122;s HIV status is not identifiable to others in any way. Public spaces should be open and high, whereas private spaces should be intimate, singular and closed off to the public eye.

C

A B

Circulation Create close proximities to make moving between A, B and C easy. The movement should follow a certain logic and should consider confidentiality between visitors and patients.

Entrance A communal main entrance should be provided. From that point visitors will be guided towards seperate departments. This aims to avoid stigmatisation and allows users to interact with each other.

138

PROGRAMME

Flexibility

A

B

Introduce flexible layouts and areas, which may accommodate different functions. Avoid rooms that are not used for a period of time.

The structure should be built in a way that it allows for future extensions and for disassemble and mobility.

Communal rooms Different spaces and departments should share communal areas. These areas and public spaces should encourage social relations between users.

Pause spaces Extend the public areas with spaces more suited for privacy.

Waiting areas Patient waiting areas should be open and well-ventilated as this is a key element of the environmental control measures needed to minimize transmission of tuberculosis. Covered outdoor spaces are preferred to enclosed indoor areas.

PROGRAMME

139

Spatial intentions The following diagrams illustrate spatial characters that I would like to integrate into the facilities:

Confidentiality Avoid creating an impression of being watched. Patients need to know that they can trust the health workers, only then will they feel comfortable.

Courtyards Courtyards and visual as well as physical links to nature should be introduced to draw sunlight into the building and to avoid a clinical atmosphere. They also serve to provide better ventilation and security.

Intimacy Spaces such as counselling rooms or treatment and testing departments should be divided into smaller units, in order to maintain an overview and a sense of intimacy.

Zones Division of rooms into different coherent zones in order to create more privacy within a space.

140

PROGRAMME

Spaces for contemplation Introduce spaces for patients where they can reflect on life and their health in a spiritual atmosphere. This should help them on their path of acceptance of their status.

Information Provide educational information and materials throughout the facilities, especially in waiting areas in order to enhance the patientsâ&#x20AC;&#x2122; knowledge about the virus and to minimize boredom while waiting.

Sunlight Introduce sufficient natural light into the buildings. This will improve health and well being of patients and staff and reduces cost of artificial lighting.

Open staff rooms The rooms for staff members should encourage exchange of information among each other. The work areas should be team based - no few personal offices.

PROGRAMME

141

Visions Adaptation Designing Architecture for HIV patients needs to be flexible and adaptive because of its dynamic organisation of services and spaces. High client loads increase the spatial challenge. More people come if services are made available. This demands a facility that can receive substantial client flows.

In addition, the architecture should envision a sustainable and feasible approach, making use of affordable local materials and building techniques, that blend into the surrounding context. The result should realise a building which is adaptive in its spatial qualities as well as its structural aesthetics.

PROGRAMME

142

Intimacy In order to avoid stigmatisation and discrimination, these facilities will have to provide patients with sufficient privacy and confidentiality. They will thus not be developed exclusively for HIV/AIDS, but rather as Centers for disease control and prevention, where the public can receive a whole range of medication , vaccines, health education and counselling. The HIV services will thus only become a smaller part of the whole building, which will be kept confidential in intimate spaces, making patients feel more relaxed and secure. The aim is to draw a diversity of patients and visitors to these centers, and thereby disguising the HIV stigma.

HIV s

d

control a ase nd e is

vices er

ion ent ev pr

HIV+

Cente r fo r

HIV+

HIV+

HIV+

HIV+

PROGRAMME

143

144

Page Title

Page Title

145

146

Page Title

Page Title

147

148

THE BRIEF

149

HIV, the virus that causes AIDS, is one of the world’s most serious health and developmental challenges. Since the onset of the epidemic in the 1980s, more than 70 million people have been infected with the virus and about 35 million people have died. Currently about 36.7 million people are living with HIV. The burden of this epidemic continues to vary considerably between countries and regions. Sub-Saharan Africa remains most severely affected, with nearly 1 in every 25 adults infected, accounting for nearly 70% of the people living with HIV worldwide.

Namibia is one of those Sub-Saharan countries highly affected by the virus. It currently has the 5th highest HIV prevalence rate in the world, with a total of 13,3% of the population infected. This has drastically impacted on the countries health indicators, posing serious developmental challenges. Providing universal access to HIV services and infrastructure, has been a priority for the Namibian government for the last ten years and 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 and financial investment.

One of the organisations providing financial support towards the HIV epidemic in Namibia is the CDC (Centers for Disease Control and Prevention). The CDC is a United States federal agency under the Department of Health and Human Services, headquartered near Atlanta, Georgia. Its main goal is to protect public health and safety through the control and prevention of disease, injury, and disability in the US and internationally.

Since 2002, CDC has helped Namibia develop and implement HIV/AIDS prevention, care, and treatment programs and assisted in building the capacity of the country’s healthcare workforce. CDC’s support has strengthened national efforts to prevent HIV transmission and to expand care and treatment services. The aim of all their support is to ensure that Namibia soon sees an AIDS-free generation.

CDC is now proposing to accelerate this aim, by means of new architectural interventions that will seek to provide comprehensive and quality treatment, counselling, prevention campaigns, testing as well as care and support for those already infected by HIV/AIDS and the ones that are at risk.

150

DESIGN BRIEF

Seeing that Namibia is so sparsely populated, these centers should focus on the rural communities, as most of them have little access to health services. Since this adresses the whole country, the proposal will have to consist of a masterplan, introducing several interventions, spread throughout Namibia´s 13 regions. In total there should be 11 new facilities, composed of a central hub and 10 smaller modules.

The central hub will be located in the heart of Namibia, in the capital of Windhoek city. It should contain a laboratory, sufficient counselling space, examination rooms, a clinic, GP offices, a pharmacy as well as a big storage space for all the medication and vaccines.

Seeing that there is a great shortage of qualified health workers in the public sector, this intervention will also have to offer educational programmes and training facilities to promote and foster existing as well as new health care workers and volunteers.

All in all the central hub will serve as a supplier to all the smaller modules, providing them with qualified health staff, medication and maintenance support.

Each of the modules will be quite a bit smaller in size and functions compared to the central hub but they will retain the core services, which consists of spaces for treatment, counselling, care and testing, as well as accommodating staff members. These units will primarily focus on reaching out to rural communities. Each unit will be equipped with several mobile clinics, covering identified areas within the country. The whole masterplan will thus work as a site network, containing small integral parts that work together in order to try and reach everyone in need.

Apart from the necessacity and function of these facilities, the architecture should envision a sustainable and feasible approach, making use of affordable local materials and building techniques.

DESIGN BRIEF

151

152

Page Title

Page Title

153

154

THE PROGRAMME

155

The proposal will consist of 11 new facilities, composed of 1 central hub and 10 smaller modules.

Central hub The central hub will be located in the heart of Namibia, in the capital of Windhoek city.

This facility will seek to provide comprehensive and quality treatment, counselling, education, prevention campaigns, testing as well as care and support for those already infected by HIV/AIDS and the ones that are at risk. The building will contain a laboratory, sufficient counselling space, examination rooms as well as a big storage space for all the medication and vaccines.

Seeing that there is a great shortage of qualified health workers in the public sector, this intervention will also offer educational programmes and training facilities to promote and foster existing as well as new health care workers and volunteers.

All in all the central hub will serve as a supplier to all the smaller modules, providing them with qualified health staff, medication and maintenance support.

Modules Each of the modules will be quite a bit smaller in size and functions compared to the central hub but they will retain the core services, which consists of spaces for treatment, counselling, care and testing, as well as accommodating staff members.

These units will primarily focus on reaching out to rural communities. Each unit will be equipped with several mobile clinics, covering identified areas within the country.

1

Windhoek - Central hub -

Region: Khomas

- Population 415 000

2

Kamanjab - Module 1

-

Region: Kunene

-

Population: 6 012

3

Okongwati - Module 2

-

Region: Kunene

-

Population: 5 078

4

Mpungu

- Module 3

-

Region: Kavango

- Population: 18 332

5

Tsumkwe

- Module 4

-

Region: Otjozondjupa - Population: 10 200

6

Kongola

- Module 5

-

Region: Zambezi

-

Population: 5 600

7

Otjinene

- Module 6

-

Region: Omaheke

-

Population: 3 400

8

Aranos

- Module 7

-

Region: Hardap

-

Population: 3 683

9

Maltahรถhe - Module 8

-

Region: Hardap

-

Population: 6 000

10

Bethanien

- Module 9

-

Region: Karas

-

Population: 2 000

11

Aroab

- Module 10 -

Region: Karas

-

Population: 5 000

156

PROGRAMME

3

4

6

2

5

7

1

8 9

10 11

Sending mobile clinics to rural communities

Supply of medication and health staff

PROGRAMME

157

158

DESIGN INTENTIONS

159

The building will have to be: 1

Functional

2

Sustainable

3

Adaptive

4

Efficient

5

Feasible

6

Innovative

7

Local

8

Durable

9

Minimilistic

10 Beautiful

160

DESIGN INTENTIONS

DESIGN INTENTIONS

161

162

Page Title

Page Title

163

164

DESIGN STRATEGIES

165

Strategies for overall building layout 1

Optimal orientation

facing north-south

North

South 2

Long narrow spaces

cross ventilation

3

Courtyards

closer to nature

x

166

DESIGN STRATEGIES

4

Spread buildings

more privacy and intimacy

x

5

Introduce spine

6

Future extensions

connect wings to each other

adapting the spaces

DESIGN STRATEGIES

167

Strategies for each wing/department 1

One room building width

2

Introduction of natural domain

Nature

3

omit every second module

Nature

Nature

Closed off vs open facades

Views

168

north-south for each module

Views

creating privacy

Views

DESIGN STRATEGIES

Views

4

Cross ventilation

5

One continuous roof

6

Extension of room sizes

avoid artificial ventilation

catchment of water

adapt sizes of rooms

3m 5m

DESIGN STRATEGIES

169

Functional layout Wings Each department is given one wing which are all connected to a single spine.

Services

Staff

Health care

Health educaation

Admin

170

DESIGN STRATEGIES

Cores Certain spaces need to be connected to the same function. These spaces are expressed in double volumes, defining the public spaces in the building and serve as a bridge, linking certain departments to each other.

Fitness

Health care

Clinic

Health educaation Library

Canteen

Staff

Storage

Records

Services

Admin

DESIGN STRATEGIES

171

Merge and compress wings with cores In order to reduce the building all the wings and cores are shifted into the same axis. This allows for a cleaner transition of functions and for a more feasible structure.

172

DESIGN STRATEGIES

Shift building blocks out of the grid Seeing that the structure will have to be built on several other sites, it is important to create flexibilty. By means of maintaining the structural layout, building blocks can simply be rotated and shifted according to the perimeters and the topography of each site.

DESIGN STRATEGIES

173

174

Page Title

Page Title

175

176

DESIGN CONCEPTS

177

Human scale The bigger the space the more insecure patients will feel.

Buildings such as counselling rooms or treatment and testing departments should be divided into smaller units, in order to maintain an overview and a sense of intimacy.

Spread buildings The site is big. Make use of it.

Building blocks that require privacy should be scattered in order to achieve visual and auditory privacy.

Open waiting areas Reduce possibility of contamination.

Patient waiting areas should be open and well-ventilated as this is a key element of the environmental control measures needed to minimize transmission of tuberculosis.

Nature as a buffer Break the clinical atmosphere Courtyards and visual as well as physical links to nature should be introduced to draw sunlight into the building and to generate a visual barrier from building to building.

178

DESIGN CONCEPTS

Screens Now you see me, now you dont.

Introduce natural timber screens wherever privacy is needed. This will make patients feel more comfortable while allowing light to penetrate into the interior.

Walkways Roaming through nature.

Long outside walkways are introduced throughout the project. This allows users breathing space and closer connection to the landscape.

Contemplation spaces Time to process.

Pause spaces will be designed along the walkways. These will allow patients to reflect on life and their health in a spiritual atmosphere. This should help them on their path of acceptance of their status.

Regulating patient flow One at a time.

In order to avoid too many patients at once, the number of people will be regulated. This will make patients feel more comfortable and minimize the chances of contamination.

DESIGN CONCEPTS

179

180

Page Title

Page Title

181

182

DRAWINGS

183

d ar on Le Dr

a al Au

et re St

184 Ha ns -D iet ric hG 11 en 07 sc 00 he mm rS tre et

23 71 00 mm

Page Title

1686

1695

1694

1693

1692

1691

1690

1689

mm 000 150

1688

N Page Title

185

Site Plan Layout - 1:1000 1686

1687

W C

W C

Be d Se rve rR oo m

Be d W C

W C

Be d Me dic al

Be d W C

W C

Re co rd s

Be d Ch an gin g

ss Cla 3 Cle an ers

Sta ff R oo m

Ga rd en

ss Cla 2

Re fus e

Pa ntr y Sc ull.

Kit ch en Ca nte en

ss Cla 1

FP

W C

Nt

fo In

G P ss ne Fit io ud St

C W g.

Re g.

Re

Le ctu re Ha ll

nic Cli

g.

Re b.

La

Lib rar y

ck to .s ed M e ffic O

y ac m ar Ph

. ch Kit . ull Sc ry nt Pa

C W

fe Ca

y rit cu Se

e 0.0.100.100

Be d

186

e ag or St

Ge ne rato r

es ag ar G

Ex

Ex

W C

Co s

Co s

G ro up

Co s

N 187

Ground Floor Layout - 1:500

Be dro om

3 Be dro om

3

Se rve rR oo m Se rve rR oo m

Be dro om

2 Be dro om

2

Be dro om

Me dic al

Re co rds Me dic al Re co rds

1

Be dro om

1 Ch an gin gR oo ms Ch an gin gR oo ms

m oo 3 ssr omCla ro ss Cla 3

Cle an ers Cle an ers

m oo 2 ssr omCla ro ss Cla

Sta ff R oo m Sta ff R oo m

Ga rde n Ga rde n

2 m oo 1 ssr omCla ro ss Cla

Fa m ily

Pla n Fa nin m g ily Pla nn ing

Ca nte en

1

Ca nte en

W C W C Nu trit io n

Co Nu un trit se io llin n g Co un se llin g

G P

fo In

G P

fo In C W

Le ctu re

C W

Ha ll Le ctu re

Ha ll g.

Re g.

Re

nic Cli

g.

Re

nic Cli

g.

Re g.

Re g.

Re

ry ato or ry b to La ra bo La

Lib ra ry/L ea rnin Lib g ra ry/L ea rnin g

y ac rm y ha ac P m ar Ph

rs ito Vis rs fe ito CaVis fe Ca

ity ur ec y S rit cu Se

Patient circulation Patient circulation Staff circulation Staff circulation Student circulation Student circulation Visitors circulation Visitors circulation

GSPublisherEngine 0.0.100.100

188

ge ra Sto

Re fus e

Ge ne rato r

es ag ar G

ss ne Fit dio Stu Ex am ina tio n

Ex am ina tio n

Co un se llin g

Co un se llin g

G ro up

Co un se llin g

189

190

DRAWINGS

DRAWINGS

191

192

193

Generator room

194

Open courtyard

General Practitioner

DRAWINGS

Patient waiting area

Registration

Waiting

Pharmacy

24h educational

Amphitheater

Visitors Cafe

Outside seating

Parking

screening

DRAWINGS

195

500 100 2400 196

DRAWINGS

Klip Lock 700 roof sheeting @ 2 degree angle fixed on top of 100x50x5mm mild steel rhs with gms klips to manufacturers specs. 40mm LAMBDA board ceiling fixed to 50x50x5mm gms angles, welded to purlins.

140x140x3mm gms gutter fixed to last @ 600mm c/c with brackets to manufacturers details and specs.

Downpipe to flow into 2000mm diameter rainwater tanks as per site plan.

30-40mm diameter timber latte @ max 60mm c/c woven around 10mm diameter steel rods welded to gms frame @ 450mm c/c. Each end to be fixed to 50x50x5mm gms angles. Timber latte to be treated with clear varnish.

Ventilation louver 150mm cavity 100mm partition wall. Internal face to be cladded with 150x25mm timber slats and external face to be cladded with corrugated sheeting.

100mm timber partition wall. Internal panel to be cladded with 150x25mm timber slats and external face to be cladded with 25mm shutterboard panels all screw fixed to 50x100mm timber battens @ max 600mm c/c.

Shutterboard face to be painted black.

30-40mm diameter timber latte @ max 60mm c/c spacing woven around 10mm diameter steel rods welded to gms frame @ 450mm c/c. Each end to be fixed to 50x50x5mm gms angles. Timber latte to be treated with clear varnish.

1500x300mm top hung aluminium window operable with exterior handle.

150x50mm salvaged timber boarding screw fixed onto 100x50mm gms frame.

All planks to be cleaned and sanded down.

Steel frame built with 100x50x3mm rhs sections. 250x250x3mm steel base plate welded to columns on top of levelling grout and, slotted through bolts cast into reinforced concrete pad footing.

DRAWINGS

197

GSPublisherEngine 0.0.100.100

198

DRAWINGS

DRAWINGS

199

2000

200

GSPublisherEngine 0.0.100.100

DRAWINGS

Roof structure built with round 70mm dia. gms columns welded to main gms columns. Water repellent ripstop canvas stretched over the steel structure to later Detail.

150x100x10mm galvanised rhs beam welded to gms columns.

steel

1000

1550

Gabion wall built with 500(h)x500(width) x1000(length)mm galvanised wire baskets. The gabion baskets shall have hexagonal woven mesh with a maximum size of 80mm x 100mm. All wire used in the manufacture of gabion wiring during construction shall be heavily coated with zinc. Stone for filling gabions shall be resourced from the site surroundings and should be between 120 mm and 250 mm dia in size. It shall be hard and resistant to abrasion, uniform in texture and without imperfections likely to impair resistance to weathering.

Exterior of gabion walls to be lined with an insect and dust screen.

1000mm high balustrade built with 100x50mm rhs and filled with 30mm diameter timber latte @ 60mm c/c spacings

150x100x10mm galvanised rhs steel column central to gabion wall @ 3000mm c/c fixed to concrete strip footing.

plate to

2000

2600

1200x500x20mm gms flat support window opening.

2x 1000x1000mm top hung aluminium windows operable with interior handle fitted central to gabion wall.

Klip Lock 700 roof sheeting @ 2 degree angle fixed on top of 100x50x5mm mild steel rhs with gms

450

150x50mm salvaged timber boarding screw fixed onto 100x50mm gms frame.

All planks to be cleaned and sanded down.

50x50mm gms angle welded to rhs purlin

Reinforced concrete strip specified

DRAWINGS

201

footing

as

202

DRAWINGS

DRAWINGS

203

204

Page Title

Page Title

205

206

MATERIAL COLLAGE

207

Gabions The walls for the two core structures will be constructed with gabion walls. Due to their big thermal mass they can resist heating up too fast and, storing the energy absorbed from the sun and releasing it over time.

The rocks used for the infill will be sourced locally from the site and its surroundings. The construction can be performed by the locals as it doesnt require skilled labour.

Salvaged cladding Salvaged and reused material such as corrugated sheeting, timber palettes, wooden boarding and shutterboard will be used for the exterior wall cladding of the lightweight steel wings.

Furthermore all the suspended walkways will be covered and laid with old timber planks, running adjacent to the length of the path.

Glass Openings for the public spaces will be installed with low E glazing in order to achieve visibilty where its needed.

The trombe walls facing North in all the lightweight steel wings will also be cladded with glass in order to reach its passive solar heating.

Latte Timber latte (poles) are a very commonly used building material in Namibia. I want to use these poles as screening devices as well as a shading instrument for walkways and parking. The spacings of the individual poles will vary according to the the function and its privacy.

Other than that the latte will give the building a natural layer linking it to the natural surroundings.

208

MATERIAL COLLAGE

Canvas The roofs of the cores will be covered with water repellent ripstop canvas. I wanted to find a method how to save added matrial for a substructure and thereby needed a lightweight and flexible material. The canvas allows for minimal steel support and it protects against rain and sun. The sheeting also allows for diffused light to enter the interior.

Nano fiber filter screens The sides of the canvas roof will be fitted with another type of fabric, which will be a nano fiber filter screen. This material keeps out most of the unwanted dust particles and insects but retains air flow throughout the building. More than that it allows for light to penetrate into the interior, reducing the need for articial lighting and ventilation.

Steel frames Seeing that the building needs to be economical and feasible, the structure will be built out of lightweight steel frames. These will allow for pre manufacture and easy assemble on site.

Other than that this modular steel layout can easily be erected on another site and extended when needed.

Polycarbonate sheeting All top level windows in the wings will be filled with translucent polycarbonate sheeting in order to save costs on glass. The sheeting will retain the required light intake. Seeing that these windows are installed under deep overhangs, the sheeting will not be exposed to direct sunlight, thus preventing it from turning brittle, and extending its life span.

MATERIAL COLLAGE

209

210

Page Title

Page Title

211

212

MODELS

213

214

Page MODELS Title

Page MODELS Title

215

216

Page MODELS Title

Page MODELS Title

217

218

Page MODELS Title

Page MODELS Title

219

220

MODULAR LAYOUTS

221

Modular layouts and their locations All of the 11 sites are placed within an existing matrix of infrastructure, covering all the regions in the country. The central hub will be located in the capital - Windhoek city and the ten modules will be placed in the following spots:

2

3

5

1

4

6 7

7 8

9 10

222

MODULAR LAYOUTS

Zoning The Central hub will consists of five departments illustrated in different zones, which consist of administration, staff, health care, health education and services. The modules will include the same departments but exclude the educational platform.: Central hub:

G SP ub lis he rE ng in e

0.

0.

10 0.

10 0

Modules:

Staff

Education

Administration

MODULAR LAYOUTS

Health care

Services

223

Module 1 Kamanjab Region: Kunene

GSPublisherEngine 0.0.100.100

224

MODULAR LAYOUTS

Module 2 Okangwati Region: Kunene

GSPublisherEngine 0.0.100.100

MODULAR LAYOUTS

225

Module 3 Mpungu Region: Kavango

GSPublisherEngine 0.0.100.100

226

MODULAR LAYOUTS

Module 4 Tsumkwe Region: Otjozondjupa

GSPublisherEngine 0.0.100.100

MODULAR LAYOUTS

227

Module 5 Kongola Region: Zambezi

GSPublisherEngine 0.0.100.100

228

MODULAR LAYOUTS

Module 6 Otjinene Region: Omaheke

GSPublisherEngine 0.0.100.100

MODULAR LAYOUTS

229

Module 7 Aranos Region: Hardap

230

GSPublisherEngine 0.0.100.100

MODULAR LAYOUTS

Module 8 Maltahรถhe Region: Hardap

MODULAR LAYOUTS

GSPublisherEngine 0.0.100.100

231

Module 9 Bethanien Region: Karas

GSPublisherEngine 0.0.100.100

232

MODULAR LAYOUTS

Module 10 Aroab Region: Karas

GSPublisherEngine 0.0.100.100

MODULAR LAYOUTS

233

234

Page Title

Page Title

235

236

APPENDIX

237

Design Progress Progress model 1:

Staff

238

Education

Administration

APPENDIX

Health care

Services

Progress model 2:

Staff

Education

Administration

APPENDIX

Health care

Services

239

Progress model 3:

Staff

240

Education

Administration

APPENDIX

Health care

Services

Progress model 4:

Staff

Education

Administration

APPENDIX

Health care

Services

241

Progress model 5:

Staff

242

Education

Administration

APPENDIX

Health care

Services

Progress model 6:

Staff

Education

Administration

APPENDIX

Health care

Services

243

244

BIBLIOGRAPHY

245

Bibliography Online sources: AIDSinfo. “The Stages of HIV Infection.“ National Institutes of Health.

Accessed December 11, 2016. https://aidsinfo.nih.gov/educationmaterials/fact-sheets/19/46/the-stages-of-hiv-infection.

AIDS info. “HIV Treatment: The Basics.“ Accessed November 28, 2016. https://aidsinfo.nih.gov/education-materials/fact-sheets/21/51/hivtreatment--the-basics.

AVERT. “Global HIV and AIDS Statistics.“ Accessed November 18, 2016. http://www.avert.org/global-hiv-and-aids-statistics AVERT. “Origin of HIV & AIDS.“ Accessed October 11, 2016. http://www.avert. org/professionals/history-hiv-aids/origin City Population. “Namibia.“ Accessed November 4, 2016. https://www. citypopulation.de/Namibia.html Countrymeter. “Namibia Population.“ Accessed November 4, 2016. http://countrymeters.info/en/Namibia HowAfrica. “10 Namibian tribes you should know about.“ Accessed January 12, 2017. http://howafrica.com/namibia-10-namibian-tribesyou-should-know-about/ Iris WS Chan, Rita WY Chung. “The Basic of HIV medicine“ Meeting psychological needs of HIV patients. Accessed November 28, 2016. http://www.info.gov.hk/aids/pdf/g190htm/05.htm Kaiser Family Foundation. “The Global HIV/AIDS Epidemic.“ Accessed November 7, 2016. http://kff.org/global-health-policy/fact-sheet/theglobal-hivaids-epidemic/.

MCA-N. “The growth in health services.“ Accessed October 30, 2016. http://www.mcanamibia.org/files/files/bd5_Health%20Services%20 in%20Namibia%20-%20Seen%20Environmental%20Learning%20 Information%20Sheet%20No.%206.pdf ScienceDaily. “Life expectancy for people with HIV.“ Accessed December 6, 2016. https://www.sciencedaily.com/releases/2013/04/130409173502. htm.

246

BIBLIOGRAPHY

UNAIDS. “HIV and AIDS estimates.“ Accessed November 15, 2016. http:// www.unaids.org/en/regionscountries/countries/namibia U.S. Department of Health & Human Services. “How Do You Get HIV or AIDS?“ Accessed September 23, 2016. https://www.aids.gov/hiv-aidsbasics/hiv-aids-101/how-you-get-hiv-aids/.

U.S. Department of Health & Human Services. “Opportunistic Infections.“ Accessed November 5, 2016. https://www.aids.gov/hiv-aids-basics/ staying-healthy-with-hiv-aids/potential-related-health-problems/ opportunistic-infections/.

U.S. Department of Health & Human Services. “What Is HIV/AIDS?“ Accessed September 23, 2016. https://www.aids.gov/hiv-aids-basics/ hiv-aids-101/what-is-hiv-aids/.

World Health Organization. “Global Health Observatory data.“ Accessed October 27, 2016. http://www.who.int/gho/hiv/en/ World Health Organization. “Namibia Health Facility Census - Analytical summary - HIV/AIDS.“ Accessed October 29, 2016. http://www.aho. afro.who.int/profiles_information/index.php/Namibia:Analytical_ summary_-_HIV/AIDS Journals and Articles: Paterson, David L., Susan Swindells, Jeffrey Mohr, Michelle Brester, Emanuel N. Vergis, Cheryl Squier, Marilyn M. Wagener, and Nina Singh.

“Adherence to protease inhibitor therapy and outcomes in patients with HIV infection.“ Annals of Internal Medicine, 133, no. 1, (July 2000): 21-30.

Seeling, Stefanie, Farai Mavhunga, Albertina Thomas, Bettina Adelberger and Timo Ulrichs. “Barriers to access to antiretroviral treatment for HIVpositive tuberculosis patients in Windhoek, Namibia.“ International Journal of Mycobacteriology, 3, Issue 4, (December 2014): 268–275.

Accessed December 2, 2016. http://www.sciencedirect.com/science/ article/pii/S2212553114000685

BIBLIOGRAPHY

247

Reports: Ministry of Health and Social Services. 2013. “Namibia Demographic and Health Survey“ HIV Prevalence by Socioeconomic Characteristics: Page 210. Report. Accessed November 19, 2016. https://dhsprogram.com/ pubs/pdf/FR298/FR298.pdf Ministry of Health and Social Services. 2015. “The Namibia AIDS Response Progress Report.“ AIDS Expenditure by Funding Source: Page 29. Report.

Accessed November 20, 2016. http://www.unaids.org/sites/default/files/ country/documents/NAM_narrative_report_2015.pdf Ministry of Health and Social Services. 2013. “Namibia Antiretroviral Therapy Adherence Baseline Survey Report.“ Figure 3: Page 31. Report.

Accessed November 20, 2016. http://siapsprogram.org/publication/ altview/namibia-antiretroviral-therapy-adherence-baseline-surveyreport/English/ Ministry of Health and Social Services. 2009. “Namibia Health Facility Census.“ Key Findings on HIV/AIDS and STIs: Page 4. Report. Accessed October 18, 2016. https://dhsprogram.com/pubs/pdf/SPA16/SPA16.pdf PEPFAR. 2013. “Costs of Treatment in the President´s Emergency Plan for AIDS Relief.“ Cost estimates: Page 5-6. Report. Accessed November 19, 2016. http://www.pepfar.gov/documents/organization/212059.pdf UNAIDS. 2016. “Global Aids Update.“ Distribution of new HIV infections: Page 9. Press release. Accessed November 28,2016.http://www.unaids. org/sites/default/files/media_asset/global-AIDS-update-2016_en.pdf Newspapers: Kapitako, Alvine. “Namibia imports ARVs from Uganda.“ New Era, April 11, 2016.

Nhongo, Kaula. “Woman overcomes HIV/AIDS stigma“ Windhoek Observer, December 05, 2014.

Interview: Wienecke, Adonia “Email interview by Olaf Buchholz.“ Windhoek, November 28, 2016.

248

BIBLIOGRAPHY

Books: Barnett, Tony & Whiteside, Alan. AIDS in the Twenty-First century. Disease and Globalisation. Hampshire and New York: Pelgrave Macmillan, 2002.

Page 3.

Gallant, Joel E. 100 Questions & Answers about HIV and AIDS. Burlington, Mass.: Jones & Bartlett, 2016. Page 14.

Ministry of Health and Social Services. National Strategic Framework for HIV and AIDS Response in Namibia 2010/11 - 2015/16. Windhoek: Solitaire Press, 2010. Page 11.

Sigall K. Bell, Courtney L. McMickens, and Kevin J. Selby. Introduction and Timeline to AIDS. Santa Barbara, CA: Greenwood, 2011.

Whiteside, Alan. Implications of AIDS for Demography and Policy in Southern Africa. Pietermaritzburg: University of KwaZulu-Natal Press, 1998. Page 22.

Documentaries: RED. “The Lazarus Effect.“ Documentary. Directed by Lance Bangs.

USA. 2010. Accessed November 25, 2016. https://www.youtube.com/ watch?v=l16YH6xCN4c&t=1212s.

Oprah. “The Lazarus Effect and Antiretroviral Drugs.“ Accessed November 25, 2016. http://www.oprah.com/world/TheLazarus-Effect-and-Antiretroviral-Drugs-in-Africa Dartmouth Films. “Fire in the Blood.“ Documentary. Directed by Dylan Mohan Gray. Germany. 2013. Accessed November 15, 2016. http:// putlocker.live/Fire-in-the-Blood-online-free-putlocker-193-1918.html.

Manual: World Health Organization. 2008. “Operationals manual for delivery of HIV prevention, care and treatment at primary health centres in highprevalence, resource-constrained settings.“ Infrastructure by Health centre area: Page 82-90. Manual. Accessed January 15, 2017. http:// www.who.int/hiv/pub/imai/om_5_infrastructure.pdf

BIBLIOGRAPHY

249

250

Page Title

Page Title

251