07-T1111: Harvard This is a continuing program through the Botswana-Harvard School of Public Health AIDS Initiative Partnership (BHP) to support and strengthen the Masa ARV therapy program through the following 4 activities: ACTIVITY 1: Clinical Master Trainer/ARV Site Support (CMT) was designed to provide a sustainable training capacity for integrated, high-quality HIV/AIDS treatment at public sector ARV sites in Botswana. It consists of on-site and centralized training and support activities, focusing on the development and training of site-level Master Trainers who in turn will provide training to health professionals at their respective sites. By end of FY06, CMT will have assessed 16 sites, initially supported and followed up with 10 sites, assessed and supported/upgraded 10 clinics to prescription and dispensing level, and trained 1200 health workers to deliver ARV services. - Number of individuals newly initiating antiretroviral therapy during reporting period = 3 000 - Number of individuals receiving antiretroviral therapy at the end of the reporting period = 19 000 - Number of laboratories with capacity to perform 1) HIV tests, 2) CD4 tests and 3) viral loads = 12 - Number of individuals trained in the provision of laboratory-related activities = 36 (including 6 from private labs) - Number of CD4s performed @ new labs- min capacity 50 samples /day - Number of individuals trained in strategic information (includes M&E, surveillance and/or HMIS)= 100

These numbers include the IDCC and satellite clinics, as well as from the 11 ARV sites where we will have an on-site presence for an estimated 24% of the fiscal year period. By the end of FY06, all sites and satellite clinics will be reached in terms of staff training, and 16 satellite clinics will be upgraded and set up as full prescribing stand alone facilities. More than 800 health workers will be provided short term trainings (KITSO for Lower Cadres, and KITSO ACCF) and in-service lectures on HIV and OI. In collaboration with WHO and MoH spearheaded the adaptation and piloting of the Integrated Management of Adults and Adolescent Illnesses (IMAAI) modules to be in line with the national roll out for nurses dispensing; implemented telephone site support, with CMT receiving more than 200 calls per month on different issues on HIV care.

In FY07, the remaining ARV sites will receive the full package of training and support (i.e., needs assessment, on-site practical support, centralized classroom and attachment training at site IDCC, immediate on-site support, and quarterly follow-up visits). A total of 32 core team site-level Master Trainers will be trained and will supervise care and treatment at their sites. Harvard will expand its clinical support to ARV sites in FY07 through these activities: 1) strategies to improve, integrate, monitor and evaluate services and programs at ARV sites, and to increase capacity through improved integration of programs. This includes training of the CMT's on QAI and implementation of QA activities in collaboration with I-TECH at the ARV site level; 2) Telephone Site Support for HIV/AIDS Management to enable clinical and pharmacy staff at all 32 ARV sites to obtain advice on difficult cases, etc. from core Master Trainers and other BHP staff by toll free phone to ensure the best, quickest, and most efficient care and treatment possible; 3) in collaboration with MASA, clinical core teams will be trained to train the nursing cadre at their sites to start prescribing and dispensing for non-complicated first line therapy; 4) Development of educational tools for ARV sites, including a clinic reference manual and CD ROMs; 5) in addition to activities 1-4, the Pharmacy Master Trainers (PMT) will provide training on Supply Chain Management, Rational Drug Use, logistics, dispensing techniques, and monitoring of toxicities for all 32 sites, and provide on-site support to 20 ARV dispensing units. The PMT will also collaborate with Central Medical Stores on forecasting, quantification, ordering and delivery of ARV drugs to the newly dispensing satellite clinics, monitoring and evaluation and developing/updating existing training manuals; and 6) increasing the pediatric effort by bridging efforts on testing and diagnosis of children under 5 years.

ACTIVITY 2: The Laboratory Master Trainer (LMT) has been instrumental in the decentralization of CD4 and viral load (VL) testing (infrastructure funded by ACHAP and BOTUSA). CD4 services were decentralized to 12 laboratories in FY06, and VL testing was delayed due to machinery incompatibility, electrical power insufficiency, and delays in

equipment delivery. A total of 25 laboratory technicians were trained on CD4 systems and 6 on VL to date. Decentralization, set up, and training support for VL testing will resume during the remainder of FY06. In FY07, the Laboratory Master Trainer/Site Support Program will continue to support the established CD4, VL decentralized and expanded labs from FY06 and add hematology, chemistry, and microbiology re-training and support. By the end of FY07, all laboratory technicians from the 12 decentralized laboratories will have been fully trained in CD4 and VL, re-trained in hematology, chemistry, and micro, and all 12 labs should be fully functional. Attachment training at the Botswana-Harvard HIV Reference Lab, site support, telephone site support, and capacity building through development of site-level laboratory master trainers will continue. An estimated 30 technicians (6 from private sector because of Private Public Partnership) will be trained. The LMT, in collaboration with MOH and BOTUSA, will formalize the training manuals on CD4, VL, hematology, chemistry and microbiology (including TB), and the LMT will train on the expanded manual during all training efforts listed above. Additionally they will provide training on lab data management, reagent logistics, and quality assurance in FY07.

ACTIVITY 3: Establishment of a Monitoring and Evaluation (M&E) Unit within the National ARV (Masa) Program to develop standardized paper-based and electronic monitoring systems to track ARV patients, specifically, clinical, laboratory and pharmaceutical monitoring systems. This would include development of indicators and data capture instruments, harmonization of indicators, development of data flow mechanisms including reporting guidelines and instruments, reporting schedules, and routine feedback documents to the sites. A data server was purchased and installed within the MOH. Ten data entry clerks were hired in April 2006 and are presently deployed at ART sites to enter manual data from files into the electronic system, and update the ARV data at all 32 sites. A data manager understudy was hired. Staff at the ART sites will be trained on the new data capture instruments, indicators, quality and flow. A consultant will be brought in to assist in setting up the data warehouse, and working on integration and security issues. Activities for FY07 will continue in line with the MOH vision of developing a viable and sustainable monitoring system for the ARV program. The existing MASA application will be evaluated and updated to serve the increasing numbers of patients who will come into the system. Additional software required for front-end users of the server will be purchased. Relevant staff at ART sites will be provided with refresher training on data aspects and monitoring and evaluation. Site visits will be continued to monitor data quality and data activities at the sites.