P0101 Ministry of Health PMTCT program.

This activity has USG Team Botswana Internal Reference Number P0101. This activity links to the following: C0613 & C0614 & C0615 & C0701 & C0901 & C0902 & P0102 & P0105 & P0106 & P0108 & P0511 & X1303 & X1304. Also links to a number of Treatment programs or activities (T1107 to T1109, T1113 to T1118).

This activity is a direct support to the Ministry of Health (MOH) and is composed of three components that address the PMTCT strategic plan, including improving human capacity and the quality of PMTCT services.

The first component addresses the expansion of PMTCT. The USG will continue to support several project positions in the national and regional PMTCT program and related MOH departments, including one national coordinator, two regional coordinators, two IEC officers, one nutrition officer, one training coordinator, one care for the caregiver coordinator, and one HIV training coordinator. This component complements the Botswana government's effort in building human resource capacity to manage the PMTCT program both at the national and district levels.

The second component of the USG support to MOH will be to improve quality of services by improving on health care providers' knowledge and skills through in-service training programs. The MOH recognizes that effective training programs are based on clear guidelines and policies and program strategies, which are revised periodically to improve service delivery and program efficacy. Accordingly, the Botswana PMTCT Handbook was recently revised and harmonized with the WHO/CDC PMTCT generic training package to provide health workers with the latest evidence-based PMTCT information and recommendations to enable providers to deliver quality PMTCT services. Efforts are ongoing to integrate PMTCT content into the current pre-service curricula at the Institutes of Health Sciences (IHS). This will ensure that health workers will be familiar with PMTCT services upon graduation from health training institutions. Meanwhile the need still exists for regular in-service training in PMTCT at all levels. This component will provide update workshops for 300 lay counselors, 150 trainers, and 24 focal persons.

The third component will be the support for the MOH PMTCT program in the area of strengthening IEC activities. The funding will be used to support the implementation of the PMTCT social marketing campaign targeting men as influencers and gatekeepers to increase their support of pregnant women. The campaign will focus on development of an overall mass media effort that links the community to PMTCT, and message efforts through radio and theatre drama that show men engaged in PMTCT services, and supporting such services. The campaign will utilize outdoor billboards across the country, electronic media, and newspaper advertising. In addition, health learning materials will be developed and distributed for the campaign. One of the fundamental principles of social marketing is to ensure that products and services are well-placed within the "normal'" path or routine of the consumer. The PMTCT program has developed, produced and reviewed IEC materials. This will ensure that continuity in the availability of information pertaining to PMTCT is maintained along with ensuring that the content of such material remains accurate. The strategic placement of these materials is, however, as crucial as to their successful use as their production.

Safe Infant Feeding

This activity links with 07-P0101,07-P0102, 07-P0103,07-P0103

Infant feeding in the era of HIV/AIDS can seem complex. Breastfeeding, long known to be the best for infant nutrition and immune system development, now comes with a risk of HIV infection for infants of HIV-positive women. Even though exclusive formula feeding can eliminate the risk of MTCT, it can lead to malnutrition, diarrheal disease, or death for the infant, even if the infant remains HIV-negative. It is the responsibility of the healthcare worker to ensure that the women are counseled to empower them to make safe choices about feeding their infants.

The recent diarrhea outbreak associated with acute severe malnutrition, during which 553 children lost their lives, emphasized the need to focus efforts to address infant and young child feeding in Botswana. A study conducted by CDC during the outbreak followed up 153 children admitted in hospital during the outbreak found that 43% of the children had prolonged diarrhea and had been discharged and readmitted at least once during the study. Many of the children developed severe acute malnutrition during or after diarrhea; 42% developed marasmus, 21% developed kwashiorkor and most were growing poorly before the onset of the diarrhea and were not being adequately managed despite monthly weighing at the clinics. A high mortality of 21% was recorded amongst these children.

Accelerated training on infant and young child feeding is also crucial to support mothers on optimal feeding in the context of HIV/AIDS as national studies reveal that health workers knowledge in infant and young child feeding is poor and infant feeding practices are suboptimal. The recently developed Botswana Training Package (BTP) contains modules with updated information on infant and young child feeding that will be used for such training. The nutrition unit in the Ministry of Health is lacking teaching AIDS and equipment necessary for training and demonstration of safe feeding practices including safe preparation of infant formula to the mothers. The use of visual teaching aids/materials such as life size baby dolls and model breasts have proven effective for such training. Lastly, the nutrition unit updated the child welfare card including the growth chart, but requires TA to upgrade the Nutrition surveillance system to be commensurate with the new child welfare card to facilitate data growth monitoring and infant feeding data capture.

In FY07 USG funds will be used to support activities aimed at strengthening infant feeding education, counseling and support. In addition, growth monitoring activities will be supported. The activities include: 1) Roll-out of training on infant and young child feeding of healthcare workers focusing on district and clinic level staff, according to BTP. 2) Development and purchase of teaching AIDS and supplies for demonstration on appropriate and safe infant feeding practices including formula preparation 3) Purchase of equipment 4) TA to redesign/update the database for the National Nutrition Surveillance System in line with the updated Child Welfare Card.

Per July 2007 Reprogramming; Add at the end of the exisiting text: The $200,000 redirected funds will be used to train more health workers and purchase additional equipment for demonstration of safe infant feeding. There are no changes to the overall targets as the original entry used the Botswana national PMTCT indicators. These funds are in addition to the previous reprogramming of funds to Infant Nutrition from Act. 10151. The activity will remain as previously entered with the same additional narrative as requested in the reprogramming of Act. 10151. There are no changes to the overall targets as the original entry used the Botswana national PMTCT indicators.

07-P0206 Ministry of Health-disability.

This activity has USG Team Botswana Internal Reference Number P0206. This activity links to the following: C0907 & P0208 & P0211.

The Rehabilitation Services Division under MOH's Public Health Department has been tasked with providing services to people with various disabilities. The study's major objectives were to find out the level of people with disabilities. Needs of information on HIV/AIDS, and their immediate and critical needs in regard HIV/AIDS.

The MOH through the Rehabilitation Services Division, commissioned a study in 2004 on HIV/AIDS awareness, education, and needs of people with various disabilities in Botswana. The study's major objectives were to find out the level of awareness about HIV/AIDS among people with disabilities, accessibility and availability of information on HIV/AIDS, and their immediate and critical needs in regard HIV/AIDS.

The national census report (Central Statistics Office [CSO] 2001) of the Ministry of Finance and Development Planning (MFDP) estimates that as of 2001, 3.5% (59,500) of Botswana's population of 1.7million are living with disabilities. HIV/AIDS affects the population indiscriminately according to a report from the CSO; in 2004 at least 25% of the 15-49 years old population was living with HIV/AIDS. This number includes people with disabilities. Although there is limited demographic information about people with disabilities, especially the HIV prevalence in the population, the latest estimate indicated that there are between 11,500 and 16,750 such individuals.

Furthermore, statistics from institutions of people with disabilities in Mochudi, Otse and Lobatse have shown that indeed there are people with disabilities presenting with HIV/AIDS related illnesses. Similarly, in the recent years, the MOH has witnessed an increase in the number of people with HIV who develop disabilities, such as visual, hearing impairments, brain nerve damage and physical disability.

The 2004 assessment specifically identified a number of issues to be addressed. People with disabilities have limited knowledge of HIV/AIDS due to a lack of available IEC material in text or other format readily accessible to them. MOH's Health Education Unit has not had the capacity or technical expertise to produce materials specifically targeting people with disabilities.

FY07 funds will support the initial efforts of developing and/or adapting, and printing or purchasing, IEC materials for people with disabilities, and the adaptation of IEC peer education training materials. Once this stage is completed, training will commence through workshops, support through organizations that serve the population, awareness activities, and peer education/peer counseling will be offered. Dissemination of the IEC information will take place during workshops.

Program Objectives for FY07 1. To continue to develop and produce IEC materials targeting the four categories of disabilities (hearing impaired, visually impaired, physically challenged, and mentally challenged). Approximately 10,000 units will be produced.

2. Create awareness among people with disabilities and their families on HIV/AIDS and HIV prevention, through dissemination of essential IEC materials.

3. Promote information sharing on HIV/AIDS information and prevention through peer education among care-givers as well as people with disabilities, when appropriate. Approximately 5 caregivers and people with disabilities from 24 districts across the country will be trained in basic peer education (total 120).

Program activities / outputs Conduct workshops on HIV/AIDS Develop and disseminate IEC materials Train peer educators and peer counselors Train a pool of health care providers who have knowledge of issues specific to people with

disabilities.

Monitoring and Evaluation M&E will include quarterly reports and a follow up assessment.

07-P0502: Ipoletse HIV/AIDS Counseling and Information Hotline.

This activity has USG Team Botswana Internal Reference Number P0502. This activity links to the following: P0209 & P0218 & P0501 & P0509.

This entry represents the OP part of the program. The program's funding is split between the two program areas (AB and OP), at approximately 40% and 60%, respectively. The reason for dividing the funding is to allow the program to address the HIV prevention, and service referral, needs of a wider range of beneficiaries than they would with funding from only one of the prevention program areas. The program's effort will reflect the funding proportions noted here.

The Ipoletse Call Centre will continue to disseminate accurate, client centered information on HIV/AIDS through its Inbound HIV/AIDS National Information Helpline (Ipoletse) which was started in 2003. The objective over the years has been to nationally disseminate quality, personalised HIV/AIDS information to callers, especially those who are affected and/or infected by the virus. Tailored and personalised interaction aimed at positive change in behavior by emphasizing the messages of "Abstinence" and "Be Faithful" to youth and young adults, as well as counseling on relationships and personal crises, including gender based violence, is available through use of a Toll Free landline connecting callers to health professionals and trained operators at the 24-hour Call Centre.

In Botswana, there are over 137,000 fixed (land) line customers compared to 600,000 mobile phone customers. The recent addition of a mobile phone line in FY06 has resulted in providing access to callers using either type of phone service. FY06 funds have also been used to add seats for two additional counselors, who are providing more intensive, anonymous counseling to those who call the phone line for more than information. Over the last two years at least over 60,000 people infected with HIV have been started on ARV therapy in Botswana. During this period the Call Centre has responded to the needs of callers on ARV therapy by providing more complex, high quality information about treatment. Marketing for the services was minimal for the first two years, and with remaining FY06 funds, the Centre will increase marketing to increase utilization of the service.

In FY07, the Centre will continue services started in FY06, in particular:

1. Cell phone as well as land line access to the Call Centre

2. Telephonic Counseling Services with an emphasis on i) adherence counseling for people on ARV therapy, ii) relationship advice for youth (emphasizing the importance of abstinence and fidelity), and iii) counseling for anxiety and depression associated with HIV+ tests, and violence.

3. Training for the nurses and counselors who answer calls is conducted every quarter. Operators will receive training in customer service, dissemination of HIV/AIDS information and counseling; specifically adherence counseling. All nurses and the operators undergo the KITSO Training (training for health care providers who deliver ARV therapy) so that they may efficiently and effectively respond to questions in the Call Centre.

4. Continuation and expansion of service marketing: declining call volumes and poor use of the call centre may be partially attributable to the lack of a comprehensive marketing and advertising strategy and user awareness campaigns. The Marketing strategy will comprise the following: i) Advertising on TV, radio, electronic media, ii) promotional materials through schools, iii) Use of the popular Talk Back program and collaboration with Youth Health Organization (YOHO) and Makgabaneng. Re-branding and re launching of the Ipoletse call centre, dissemination of stickers and posters, participation in exhibitions, and networking with other stakeholders will help advertise the call centre in both rural and urban areas.

In addition, the service is considering the inclusion of a special line for health care workers with questions about ARV therapy. Other donors may support that part of the service, and some of the basic costs of the service that are funded by USG would contribute indirectly to that.

Program activities / outputs 1.Target of 3,000 service calls per month 2.Adaptation of knowledge base of counselors to reflect current caller needs e.g. AB messages 3.At least 500-1000 people counselled per month 4.At least 2,500 cell users interactions per month 5.Revised, updated information database ready for use in October 6.Quarterly staff trainings 7.Revised manual for counseling developed and installed in HEAT system (spell out)

Performance Management, Reporting, M&E Performance management is a key component leading to improved results. The following key performance indicators will measure success of the program: 1.Call quality monitoring 2.First call resolution 3.Attainment of service level (85% calls in 15 mins with abandonment rate of <3%) 4.% Calls offered vs. % calls answered. 5.% Calls abandoned.

07-C0613: MOH-Basic Palliative Care.

This activity has USG Team Botswana Internal Reference Number C0613. This activity links to the following: C0601 & C0602 & C0701 & C0703 & C0704 & C0801 & C0802 & C0805 & T1101 & T1111 & T1112 & T1113 & T1114 & T1115 & T1118 & T1120. Also links to a number of Palliative Care programs and activities (C0603 to C0618), OVC/NGO programs and activities (C0806 to C0816) and a number of PMTCT programs or activities (P0101 to P0108).

In 2005, an estimated 272,000 people were living with HIV/ AIDS in Botswana. PLWHA suffer from chronic life-threatening illnesses and require palliative care services to help them manage their illnesses and maintain as high a quality of life as possible. Through USG support, 250 health workers were trained in FY 05 and 100 health workers in FY 06 to provide palliatve care services. Funds were also allocated to develop training modules. Mildmay International was engaged as a consultant to 1) provide technical assistance, 2) develop training materials, and 3) train health care providers in the public and private sector as well as the civil society. Mildmay will assist the MOH in developing policies related to pain and symptom management (e.g., narcotics). Human capacity in the MOH PCU was strengthened with the recruitment of three consultants, two who have expertise in palliative care and one in opportunistic infection (OI) management. Clinical guidelines for management of OIs were revised in 2004, and will continue to be revised periodically as needed. Training in OIs will be supported by the OI consultant. In addition, the Global Fund supported the recruitment of 204 lay counselors who were trained in basic HIV/AIDS counseling. Families and communities in Botswana have demonstrated a willingness to support sick members, and they are actively involved in CHBC for PLHWA. However, most PLWHA and their care takers experience care related burdens and/or stigma. Therefore, there is a need to strengthen psychosocial support for PLWHA, and to continue training lay counselors and family welfare educators so that psychological support in the community may continue and expand. The MOH PCU will train 90 lay counselors to be empowered in addressing issues related to psychosocial support for PLWHA in the community.

In 2007, EP funds will support the following activities:

1. Organization of basic palliative care training sessions. The MOH PCU developed a training module in FY05 for the purpose of training health care workers as well as NGOs, CBOs, and FBOs dealing with palliative care. In FY07, the module will be adapted to suit training of care givers in the community. The training of trainers model will be used to roll out palliative care training countrywide, and to ensure sustainability. A total of 50 health care providers will be trained in basic palliative care.

2. The GOB intends to review the clinical guidelines for the management of OIs to integrate TB, PMTCT, and highly active antiretroviral therapy (HAART), and to strengthen the pediatric component. Training for clinicians, lay counselors, and family welfare educators will be held in the use of these revised guidelines in collaboration with the BHP CMT and Baylor COE for provision of technical expertise in adult and pediatric palliative care.

3. Of the 204 lay counselors who were recruited using Global Fund against AIDS, Tuberculosis, and malaria (GFATM) funds, 90 will be trained specifically in psychosocial support counseling to help communities cope with the burden of HIV/AIDS-related care. The lay counselors will initially be deployed to districts identified in 2007 to scale up this activity. 4. An NGO coordinator will be recruited for the MOH PCU. This person will assist in coordinating the palliative care services of NGOs, CBOs, and FBOs in the country. Efforts will be made to create linkages between care and treatment services to ensure a continuum of care. FY07 funds will also continue to support the two palliative care officer positions hired for the MOH in 2005.

5. Enhancing the nutritional status of PLWHA and affected families is a major focus of the PCU. PLWHA can stay healthy and live for many years if they receive good preventive care, good nutrition, and early treatment of common infections. Whereas access to ARVs has the potential to extend and improve the life of HIV infected people, providing nutritious food also helps infected people stay healthy and fight off infections. Despite the

fact that Botswana has a national program that provides technical guidance and support to all stakeholders on issues related to nutrition, the nutritional status of PLWHA and their families is one of the greatest challenges facing the health sector. PLWHA and their families are more likely to be living in poor households that do not have access to adequate food, and are less likely to have nutritious meals. In addition, HIV-negative children living in families affected by HIV have a higher risk of poor health and nutrition. In FY07, The PCU will sensitize and train health care providers and communities on the nutritional needs of PLWHA. This activity will be done in collaboration with Botswana Network for People living with HIV and AIDS (BONEPWA) and the Nutrition Rehabilitation Project (MOH). The unit also proposes to scale up activities on food security that are currently being implemented by two support groups under BONEPWA. Four additional support groups will be supported to establish poultry and vegetable gardens initiatives. This will help wean patients off total reliance on the government for food basket rations.

The PCU will collaborate with the DSS in the MLG to ensure that needy PLWHA and their families have access to food baskets and other basic social services. The unit will also work closely with NGOs/CBOs/FBOs that provide palliative care to ensure that PLWHA and their families have access to proper nutrition.

07-C0701 Ministry of Health.

This activity has USG Team Botswana Internal Reference Number C0701. This activity links to the following: C0613 & C0614 & C0703 & C0704 & C0708 & C0902 & P0101 & T1101 & T1111 & X1410.

A significant increase for HIV/TB activities has been programmed for FY07 to further integrate HIV/TB care with core programs for PLWHAs. To increase the use of HIV/AIDS care and treatment services, EP funds will be used to expand RHT among pediatric and adult TB clients, suspects, and contacts; intensify TB case-finding among ART clients; strengthen referral mechanisms for HIV-infected TB patients; and train clinical staff to support these objectives.

HIV-infection significantly increases morbidity and mortality in TB patients. In Botswana, HIV prevalence increases have fueled a near-doubling of TB incidence in the last decade. It is critical that all TB patients receive an HIV test to inform them of their status, and to link them to appropriate care and treatment for both diseases. HIV testing is a gateway to a package of interventions that can reduce the dual burden of HIV/TB, by connecting patients to ARV, CPT or STI treatment.

In FY07, EP funds will continue to provide TB/HIV program support for several continuing and new activities. Given pervasive human resource shortages in Botswana, investments in training will provide continuity to programs, encourage staff retention, and improve institutional memory. Training investments also will improve quality of care for HIV-infected persons with TB, by exposing staff to new information, techniques, and policies-an essential strategy where continuing medical education for medical staff is not a requirement for job retention. As a result of pervasive human resource shortages and high staff turnover, maintaining high levels of training among staff has proven to be a critical need throughout the TB program.

1) General program support to the BNTP is requested to continue expansion of routine RHT services for TB clients through training and supervisory outreach; provide training to clinic-level health care workers (HCWs) on rapid-HIV testing to increase RHT uptake; increase the number of TB patients referred to and receiving HIV care by assessing and strengthening referral systems; implement systems for TB screening in HIV care and treatment settings; provide training on TB/HIV surveillance and strengthen R&R activities to improve national TB/HIV surveillance data quality.

2) Support will also be used to monitor increases in RHT uptake in TB patients, and referral to HIV care and treatment. A cross-sectional survey will be conducted in a 50% sample of high HIV-burden districts to measure HIV testing uptake, determine impediments to testing uptake, and develop strategies to overcome them.

3) Continuing support is requested to provide HIV-infected persons with TB prophylaxis through the National IPT Program, which has registered 50,000 HIV-infected persons since 2001. Funds will be used for staff salaries, training in all 24 districts, and to finance supervisory visits by regional program- and district-level coordinators. Funding is also requested to conduct a program review, to provide quantitative measures of progress. While clinical trial data have demonstrated the effectiveness of IPT in decreasing the morbidity and mortality from TB in HIV-infected persons, its efficacy under program conditions has not been demonstrated. An evaluation will provide Botswana (and other EP settings) with essential data on the efficacy of IPT.

4) Continuing support is requested for TB/HIV surveillance activities utilizing the Botswana electronic tuberculosis register (ETR). As 60-86% of TB patients are co-infected with HIV, maintenance of this system is essential to monitor and evaluate the care provided to 5800-6300 PLWHA who are suffering from active TB disease. The ETR is a surveillance system developed by HHS/CDC/BOTUSA and used by MOH; it contains treatment data for the >10,000 TB patients enrolled annually. As an electronic R&R mechanism, it assists HCWs to ensure that all TB patients have been HIV-tested and referred for ARV treatment and CPT programs as appropriate.

5) Support is requested to fund 4 BNTP staff to attend the 2 week intensive management

course at the IDM in Gaborone. This course is run by technical experts trained in public health program management through the SMDP program at CDC in Atlanta. Course participation will advance skills to manage the challenges of developing and providing services to HIV-infected TB patients, and will help build institutional capacity within the BNTP.

6) During FY06, BNTP developed an infection control manual aimed at preventing TB transmission to HIV-infected persons in congregate care settings. We request support to print and disseminate this manual, which will be finalized with technical assistance from WHO/AFRO in late 2006. Support will also be used to train HCWs on new infection control guidelines and to pilot these in a sample of health care settings. We will also work with BNTP to assess HIV testing barriers among HCWs. HCWs who have not been HIV-tested may be at the greatest risk of TB; identification of barriers to testing will be used to develop mechanisms to provide all HCWs with the opportunity to know their HIV status.

7) 2007 Drug Resistance Survey (DRS). Mortality among HIV-infected TB patients with drug resistance is greater than 70%. NTP program reviewers recommended that Botswana "urgently plan and perform a drug resistance survey" as one has not been performed since 2003. Several factors support this recommendation: DRS of mycobacterium Tuberculosis isolates have detected steadily increasing levels of drug resistance in Botswana since 1995. Further, recent survey data from nearby Kwazulunatal Province, South Africa shows high levels of multidrug-resistant TB (37%) and extensively drug-resistant TB* (14%)(XDR TB is resistant to all first-line and at least three classes of 2nd-line drugs). Case-fatality rates for patients with XDR were 92%; of those tested, all were HIV-infected. Periodic DRS help maintain necessary laboratory infrastructure for surveillance. The DRS will also provide crucial data to monitor INH resistance levels, thus ensuring the continued utility of IPT for HIV-infected persons. TB patients are a sentinel population for HIV surveillance, and the proposed 2006 DRS will include HIV surveillance of sputum.

8) Support is requested for a new programmatic activity to enhance intensified TB case-finding in PMTCT settings. Through this activity, BNTP will establish procedures to systematically screen HIV-infected pregnant women for active TB in the Francistown area. TB suspects will be referred to the TB program for appropriate care. Support will be used to hire a FT study coordinator, and to support local travel for the study.

9) Support is requested to expand the Community Care Program through which home-based care and treatment is provided to PLWHAs and HIV-infected TB patients by a cadre of trained lay health workers and community volunteers. This program, developed collaboratively with WHO, lessens the burden on HCWs, improves adherence to ARVs and TB treatment, and helps minimize TB transmission to HIV infected persons by lessening the time spent in crowded clinics.

Funding will be used to provide suppot to the Botswana TB/HIV Coordinating Committee to convene monthly meetings to harmonize HIV/TB collaborative policies and activities at the national level.

This project encountered several delays and hence its implementation starategy was revised. Due to the urgency to provide services to malnurished children infected by HIV, the funds have been moved to service delivery within existing MOH's infrastrure complexes.

07-C0902 Ministry of Health.

This activity has USG Team Botswana Internal Reference Number C0902. This activity links to the following: C0610 & C0701 & C0901 & C0903 & C0910 & C0912 & P0101 & T1201.

VCT is a key priority of Botswana NSF. It is absolutely essential that people know their HIV status. Many of the subsequent steps in the national response are dependent on the public being tested. Indeed, only once they have tested can individuals access the appropriate services. Botswana's MOH has set objectives for the year 2007 in line with the Botswana NSF 2003 - 2009 and the EP five-year strategic plan. The objectives are:

•Develop and disseminate the national guidelines and service delivery standards, including monitoring and evaluation tools for HIV counseling and testing •Increase the number of sites providing VCT, to include NGO/CBO/FBO •Improve, standardize and expand the scope of HIV/AIDS counseling and testing training by; - training HIV counselors in counselor supervision - training of HIV counselors in couple HIV counseling and testing •Strengthen and scale up routine HIV testing in the public service

Most of these are activities from FY06, and will be continued through FY07.

Development of National Guidelines The development of national guidelines began during FY06. One of the first steps was the identification of a consultant to work with the MOHi through a reference group, to develop a comprehensive set of guidelines and service delivery standards for counseling and testing. These include guidelines for CT in the various settings (e.g. client-initiated VCT sites, and public health facilities for routine HIV testing). This activity commenced during FY06 and FY07 funds will support the completion of the activity, which will cover production, printing and dissemination of the guidelines.

Increase in the number of NGO/CBO/FBO sites providing VCT The goal of the Botswana NSF is for 95% of sexually active adults to have been counseled and tested by 2009. Consistent with this plan, the USG will support the MOH in the expansion of VCT to at least six more NGO/CBO/FBO sites in remote rural areas of Botswana. During FY06, an independent contractor was identified to work with the MOH through a CT reference group. A rapid assessment of NGO/CBO/FBOs sites capable of providing CT will be conducted and a plan for strengthening their capacity developed.

In FY07 USG will provide funding for provision of CT services at these sites, to include training of counselors, procurement of rapid test kits and consumables, mentoring support and monitoring and evaluation. Being a member of the CT reference group chaired by the MOH, Tebelopele VCT centers will use their extensive experience in providing VCT to guide the expansion of services to these additional sites. The new sites will become part of the referral networks that been established in various locations of the country to enhance referral of clients to care and treatment and to community-based support groups.

Human resources and capacity building The USG will continue to support capacity development by funding the salaries of 2 program counselor trainers. Through a mechanism still to be determined, two additional positions for CT technical officers will be funded in FY07 to enhance their capacity to coordinate the implementation of planned activities. The capacity at the MOH, counseling sub-unit will be further strengthened through refresher courses of these staff as new knowledge and training modules are developed.

Training and quality assurance The USG will continue to support the MOH in funding training of health workers in various aspects of CT service delivery. Having trained over 80 trainers in FY05, Tebelopele is preparing to scale up training on couples counseling and testing in about 12 districts during FY06. With the support of the USG, the MOH will provide training for health workers in all the 26 districts in the country. In addition to supporting the "Care for the Care Givers" program that was launched in FY06, the USG will work with the GOB to

develop a counselor supervision training program. Using FY06 funds, a core team of master trainers will be trained in counselor supervision. Technical support for this training will be obtained from the Africa region. In FY07, counselor supervision training will be rolled out to all the 26 districts. These trainings will be a crucial component of ensuring quality of counseling and testing services in the country.

Routine HIV Testing Routine HIV testing was established in Botswana in 2004 as a strategy to "normalize" HIV testing, to get more people tested and referred to treatment and care, and to strengthen prevention. As a result of this strategy, the number of tests performed in the public sector increased by 134%, from 60,846 in 2004 to 142,468 in 2005. Eventually, the program aims to expand routine testing to the private sector as well.

Many challenges still remain in the provision of routine testing in Botswana. For example,

•Although district-level trainers were trained in routine testing with the view of rolling out training to health workers in their districts, this did not take place. •There is an inconsistent supply of rapid HIV test kits in some facilities. •Health facilities lack the human resources needed to take on increased HIV testing and counseling. •Policy guidelines are not available to most health workers, and •The private sector has not been adequately brought on board to provide routine testing.

To address these gaps, the USG will assist the GOB with funding to conduct an evaluation of the strategy, train health workers in how to provide routine testing, including training in how to perform the rapid tests. The assistance will include procurement of rapid test kits for the facilities.

A recent positive development is that the MOH and the Nurses Association of Botswana have resolved a long standing issue relating to rapid testing. Where nurses previously declined to perform rapid testing, they now have agreed. They will need to be trained to be able to play this role. Facility-based refresher training to those already trained will also be provided.

This activity will add to the number of health workers being trained in how to perform rapid HIV tests and the accompanying EQA to ensure quality of HIV test results. In the COP FY 2007, under Lab support to the Ministry of Health (MOH), there are plans for a linked activity to train health workers (nurses, lay counselors and other HIV/AIDS counselors) from civil society. These plus-up funds will be used to expand that training and EQA support to additional civil society (NGOs/FBOs/CBOs) health workers. An additional 100 counselors will be trained, and follow-up support for quality assurance will be done at the sites. Training will be conducted by the MOH and the Tebelopele VCT centers. This activity is a collaboration between Lab and Counseling and Testing. The plus-up funds will be channeled through the existing cooperative agreement between CDC and the Government of Botswana (U62/CCU025095).

07-T1001 Ministry of Health-CMS.

This activity has USG Team Botswana Internal Reference Number T1001. This activity links to the following: T1002 & T1003 & T1004 & T1005 & T1115.

CMS is a unit of Pharmaceutical Services under MOH's Department of Clinical Services. It is entrusted with the responsibility of providing the nation with high-quality and cost-effective pharmaceuticals, laboratory and related medical supplies in a timely way. It serves all government health facilities, missions, mine hospitals and non-governmental organizations in Botswana. CMS is integral to the successful distribution of free ARVs to the approximately 68,440 adult and pediatric patients currently on treatment.

The ARV program is faced with a number of challenges such as 1) shortages of skilled staff, 2) inadequate storage and office space, 3) inadequate logistics skills, 4) inadequate quality assurance skills, 5) inadequate ARV security infrastructure, and 6) limited funds. GOB has received assistance from partners such as the EP, Bill and Melinda Gates Foundation, Merck Foundation, Boerhinger Ingelheim and Pfizer in the form of donations of ARVs and drugs for the treatment of OIs and price reductions.

With the assistance of EP in FY05 and FY06, CMS has been able to procure ARVs, strengthen the security system, pre-qualify suppliers, and train staff on supply chain management procedures to improve organizational efficiency and effectiveness. FY07 funds will supplement procurement and distribution of drugs for ARV therapy and other medications and supplies used to treat OI in the management of HIV/AIDS. Supplies will help support HIV/AIDS treatment services for PLWHAs, their families, children, and caregivers. In FY07 EP support will increase access to treatment through support for drug distribution to additional sites. An estimated $1,500,000 will be used to procure pediatric ARV drugs.

To meet the increasing distribution needs, CMS will procure two refrigerated vehicles and two five-ton self loading trucks with appropriate features for security and carriage, and install self loading mechanisms in its current fleet to strengthen the distribution of antiretroviral drugs. These vehicles will expedite the delivery to new sites and the health facilities. The refrigerated vehicles will help maintain the cold chain for medicines that require controlled temperature storage from CMS to the health facilities, thus maintaining their quality to the end user. The two five-ton trucks and the current fleet with self loading mechanisms will be used specifically to transport ARVs in locked cages to the ARV sites. Only the consignee will be able to unlock and unseal the cages, thus improving security. These changes will also shorten the offloading time and hence speed delivery. In addition, CMS will purchase drugs for OIs, HIV test kits, reagents and related medical supplies for the new ARV sites and health facilities countrywide.

CMS will use EP funds to procure and install a computerized temperature monitoring system with a control station for the entire warehouse and adjacent stores, since different drugs have different storage requirements. The system will provide alerts if the temperatures are outside the set limits and ensure that temperatures are monitored 24 hours a day, and any breakdown of the air condition system is attended to immediately. These protective features are especially important in the extremely hot desert weather that characterizes Botswana most of the year.

07-T1003: MOH-Drug Regulatory Unit

This activity has USG Team Botswana Internal Reference Number T1003. This activity links to the following: T1001 & T1004 & T1005 & T1111 & T1112.

MOH's DRU is the unit that is responsible for the regulation of medications in Botswana. With the expansion of the Masa program and the increase in number of patients on antiretroviral (ARV) medications, the Ministry has faced a number of challenges in the provision of the medications. In particular, increasing costs necessitated looking at different options for sources of ARVs, including generics. To ensure that the quality of the products used would not be compromised, it was necessary to strengthen the DRU. The areas that needed to be improved included the inspectorate, registration, and setting up and strengthening of a pharmacovigilance section.

In FY05, the DRU was allocated funds to train staff in (1) GMP, (2) evaluation of applications for registration, (3) pharmacovigilance, and (4) to start setting up the pharmacovigilance section. Five officers have completed training on evaluation of application of new drug dossiers, and one officer has participated in attachment training at a pharmacovigilance center. Six officers will be trained on GMP in November 2006, and three of those officers will receive additional practical training on conducting GMP inspections. FY05 funds also purchased a vehicle to assist in carrying out inspections at facilities where medicines are distributed and dispensed.

The activities for FY06 were aimed at strengthening the regulation of medicines and constructing the framework for pharmacovigilance activities across the country. These activities include: • Medicines used for the treatment of HIV/AIDS and related conditions are relatively new and it will be necessary to detect, monitor, assess, and prevent incidences of Adverse Drug Reactions (ADR). DRU staff received training to increase their knowledge based on the assessment of ADR reports to ensure that association with the drugs is established. All healthcare providers in the country will also need to be sensitized to this need and trained to report ADRs, and to help DRU regulate these medicines effectively. This will improve the safe and rational use of these medicines. • Efficiency of registration of medicines will be improved by developing clear and updated guidelines to help shorten the evaluation process, and expedite the registration of generic ARVs and other drugs. • Develop Standard Operating Procedures (SOPs) for the DRU. • Train staff on GMP inspections of manufacturers of active pharmaceutical ingredients (APIs), and conduct inspections of API manufacturers. • A document management system is essential to improve efficiency. The system will help track the evaluation process, generate reports at different stages of the evaluation process, and generate market authorization of the products. A reference text was purchased to help in the evaluation process and to ensure that up-to-date information can be accessed easily.

The activities for FY07 will be aimed at strengthening activities initiated in FY05 and FY06. These will include: •Continued training for DRU staff on pharmacovigilance and good clinical practice in bioequivalence studies for the registration generic drugs. •Training will be provided for other health care professionals in reporting of ADR. •Development of a monitoring and evaluation system of the processes within the unit. •Development of a quality management system.

The expected outputs of these activities are that the unit will have a quality manual, updated SOPs, and staff with improved skill levels. The DRU will have a monitoring and evaluation component which will help with the continuous improvement of processes and procedures to allow for effective regulation of medicines. DRU will be linked to the NDQCL system to allow the unit access to drug test results.

07-T1004: MOH-National Drug Quality Control Laboratory.

This activity has USG Team Botswana Internal Reference Number T1004. This activity links to the following: T1001 & T1003 & T1005 & T1111 & T1112.

The NDQCL ensures that medicines and related medical products that are produced, imported, exported, distributed, and used in Botswana are of acceptable quality, safety, and efficacy through testing. Since the inception of the laboratory in 1991, there has been a continuous decline in the testing of medicines and related medical products. Instead, there has been a heavy dependence on the manufacturer's documentation on the quality of medicines and related medical products that are imported, distributed, and used in Botswana due a to shortage of skilled staff. The Botswana Government has approved and supported the construction of an independent and expanded NDQCL by the end of the National Development Plan (NDP) 9, as stipulated in the Botswana National Drug Policy of 2002 in assuring the quality of medicines in the country.

One major challenge that NDQCL foresees is being able to sustain testing each batch of ARV medicines and OI medicines supplied in the country, given the shortage of skilled manpower and current laboratory space. Further, the NDQCL is also tasked with the responsibility to test all other medicines and related medical products distributed and used in the country. However, testing each batch of ARV medicines and OI drugs circulating in the country is pivotal, as it will assist in detecting counterfeit or substandard drugs that are increasingly used worldwide. Currently there are more than 1,000 medicines on DRU's List of Drugs Allowed in Botswana, and more than 1,000 medicines and related medical products that are supplied and distributed through CMS to all government health facilities, mission and mine hospitals, and some non-governmental organizations. These medicines and related medical products also require quality testing to be performed on continuous basis for pre- and post-marketing surveillance.

In FY 05/06 EP funds were used to strengthen the testing of ARV drugs through training, capacity building, and purchasing resources. Resources purchased include Primary Reference Standards for ARV Drugs, and reference books such as the US Pharmacopoeia that contains official test methods.

FY07 funds will continue to assist strengthening the quality control of ARV medicines and OIs drugs that are imported, distributed, and used in the country through three activities. 1. Training of staff (old and new). Training will be done through practical training and short courses to improve staff analytical skills, introducing staff to new analytical techniques and instruments/equipment that will assist in producing accurate test results in the shortest time possible. The training will also include ISO/IEC 17025 Standard in order to establish a quality management system in the laboratory. 2. The second activity is the continuation of the procurement of reference textbooks that contain official test methods of ARV medicines and drugs to treat OIs, and the procurement of ARV primary reference standards in order to continue testing each batch supplied in the country. 3. The third activity is to provide support in information technology (IT) capacity building. Careful selection of a suitable LIMS software package is essential to ensure accurate control of the data produced in the various NDQCL laboratories. Adequate data management involves accuracy of test data/results determination and recording, sample management, instrumentation, inventory, quotations and orders, equipment calibration and maintenance, and other activities. NDQCL will have six laboratories, including physicochemical, microbiology, medical devices, pharmaco-toxicology with animal house, pharmaco/phytochemical, and research/development. LIMS will also be used to link the NDQCL to the Drugs Regulatory so test results of the medicines analyzed and other relevant information can easily be accessed. A study tour will be conducted to at least three organizations/laboratories where LIMS is already installed.

07-T1107: MOH-Pediatrics.

This activity has USG Team Botswana Internal Reference Number T1107. This activity links to the following: C0615 & C0801 & C0802 & C0803 & C0809 & C0811 & C0813 & C0814 & C0815 & C0816 & P0101 & T1101 & T1113.

The MOH has taken a strong lead in treatment of both adults and children with HIV/AIDS. GOB reports that more than 5,700 have been started on treatment nationwide. More than 1,500 of these have initiated treatment at the Baylor COE in Gaborone.

The exact number of children infected by the HIV virus in Botswana is not known. It is estimated that 25,000 children under the age of 15 years are infected in Botswana. Additionally, it is estimated that over 111,828 (2001 population and housing census report) children have been orphaned by AIDS in Botswana.

In a pilot program to identify infected infants of HIV-infected mothers as early as possible and refer the HIV infected infants to treatment early, infants of mothers in the PMTCT program were tested at 6 weeks of age using polymerase chain reaction (PCR) on dried blood spots (DBS). This pilot showed that the prevalence of HIV in early infancy has been dramatically reduced to approximately 7%. In FY2007, the GOB will roll out this program nationally with USG funds and other support. Because this program was piloted in the GOB clinics in "real life" settings, we expect this rollout to be smooth and successful. The next challenge will be to ensure that infants identified as HIV-positive will be referred effectively for treatment according to guidelines. Followup of HIV infected infants was the biggest challenge identified in the diagnosis pilot.

The early infant diagnosis approach will capture only newborns in the PMTCT program beginning with infant cohorts in FY07. Many older HIV infected children have not been identified as infants and toddlers; they are missed by the health care system until they become ill.

In FY05 and FY06, the Department of Pediatrics in Princess Marina Hospital (PMH) has worked closely with Botswana-Baylor Children's Clinical COE to provide comprehensive care and treatment to children with HIV/AIDS in Botswana. The number of children needing treatment has declined dramatically as shown by the early infant diagnosis project due to massive uptake of the strong PMTCT program. However, a large number of children are in care at facilities around the country and the need for pediatric care and treatment is increasing as more infected children are identified, so the capacity to treat this population must be expanded.

In FY07, activities will include: Activity 1: Create referral linkages between the Pediatric Infectious Disease Clinic (PIDC) and community-based NGOs, CBOs, and FBOs so that all eligible HIV infected children in Botswana have access to treatment. Visits will be made to these organizations to identify infected children and refer appropriately.

Activity 2: Consolidate and strengthen current outreach activities, in collaboration with Baylor COE. Outreach activities thus far have included screening the home environment to identify barriers to adherence, and also encouraging family members to test and know their status. Additional activities in FY07 will include implementation of home adherence strategies, engendering intra-family support for children on therapy, provision of care for those few that are terminally ill, and addressing bereavement issues.

Activity 3: Create linkages between the PMTCT program and all clinics that are involved in infant follow up to facilitate access to the testing and treatment programs through early and effective referral.

Activity 4: Continue to support the positions of two pediatricians at PMH and two at NRH who will work at these referral hospitals and conduct outreach visits at 10 sites in the southern and northern regions, respectively.

The funding Mechanism will change to 5281, and the New Prime Partner will be Ministry of Helath. It has become apparent that it is anapropriate to award this activity as an individual activity through the gap 6 mechanism. The same activity can be conducted more efficiently, quickly and intergrated if the funds are directed to the Ministry of Health PMTCT Program and then contracted out to a local consultancy firm.

Table 3.3.12: Program Planning Overview Program Area: Laboratory Infrastructure Budget Code: HLAB Program Area Code: 12 Total Planned Funding for Program Area: $ 5,107,208.00

Program Area Context:

The public laboratory network in Botswana is a referral system with 31 government labs, 3 mission hospital labs, and 3 private sector labs in the mines. GOB labs include 3 clinic labs, 16 primary hospital labs, 6 district hospital labs, 1 national health lab, 2 referral hospital labs, and 3 reference labs. In addition, there are 15 other private sector labs as well as about 35 VCT center labs.

In order to implement Botswana's National Strategic Plan GOB must strengthen its laboratory systems- -develop and implement a quality assurance (QA) program, improve lab infrastructure, develop systems for equipment procurement and maintenance, and procure reagents and lab supplies. Efforts to improve lab services became all the more important when Botswana introduced HAART on a national scale in January 2002.

Services, referral and linkages The USG has 6 main objectives in supporting laboratory improvements: 1.Increase the number of labs that can provide CD4 and viral load (VL) testing, and modify the guidelines to improve the feasibility and sustainability of monitoring ART patients. 2.Improve laboratory infrastructure. 3.Develop a QA program. 4.Expand early infant polymerase chain reaction (PCR) testing on dried blood spots. 5.Improve overall human capacity for laboratory. 6.Develop a system for equipment procurement and maintenance, as well as reagents and laboratory supplies.

1. Monitoring ART Patients: Botswana, with the help of partners such as Bristol-Myers Squibb, African Comprehensive HIV/AIDS Partnerships (ACHAP), HHS/CDC and the Harvard AIDS Institute, has been able to establish 2 reference labs with CD4 and viral load capability. However, monitoring patients under treatment is a challenge due to excessively frequent monitoring, the long turn-around time, and the backlog of samples at both these labs. In FY05 and FY06, support to increase the capacity of the 2 reference labs, equipment and staff were provided, and additional sites were created. Since then, turnaround time has improved slightly, allowing an increase in enrolment of new patients in the ARV program. Quarterly VL testing has generated high costs for reagents and for the associated training and infrastructure. For this reason, revision of the guidelines for laboratory monitoring of patients on ARV therapy is critical, and will be addressed in FY07. We anticipate that recommended frequency of routine VL monitoring will be reduced from 4 tests per patient per year to 1 test per patient per year. This will reduce sample numbers, allowing labs to keep up with demands, and in turn reduce the turn-around time and total laboratory costs. Discussions are also ongoing about possibly reducing the frequency of CD4 counts that could also reduce the number of samples labs receive. In the meantime, there is an urgent need to continue the decentralization of VL testing to 3 additional sites. Enrollment of patients into the national ARV program has been delayed because of long turn-around times, which vary from 1 to 3 months. Over several years, CD4 testing has been expanded to 20 additional sites and has reached most areas of the country. In FY07 it will be expanded to reach 1 additional site. In addition, CD4 testing will be piloted in 2 Tebelopele VCT centers in order to provide effective palliative care to VCT clients who test positive and to assist with the decongestion of the district hospital IDCCs. 2. Improve laboratory infrastructure. Improving Botswana's laboratory infrastructure and strengthening the national QA program is vital to ensuring long-term sustainability. The district and primary hospital labs were built to receive small volumes of laboratory samples. However, with the addition of HIV-related laboratory tests (CD4, VL, infant diagnostic, HIV serology and rapid HIV tests) and the high volume of samples for other laboratory tests (hematology, chemistry, TB) have drastically increased the workload. Space and equipment at labs are inadequate to perform the testing. In FY05 and FY06 five sites were renovated and equipment and supplies were provided to district and primary hospital labs. In FY07,

additional permanent infrastructure development will continue through construction. 3. Quality Assurance Program. Since 2001 the USG team has worked closely with the MOH to develop a quality assurance program, a national policy addressing laboratory testing, and the HIV rapid test policy. Several workshops on documentation were organized; standard operating procedures (SOPs) were written; and a quality assurance manual was developed to implement the program. FY05 and FY06 funds strengthened the quality assurance program in the country by enrolling the existing reference labs in an External Quality Assurance and Proficiency Panel testing, as well as setting up a National Quality Assurance Laboratory to support the National Quality Assurance System (NEQAS). FY07 funds will be used to enroll 3 reference labs in an accreditation process. The process will include laboratory assessments by the accreditation board, and preparation for the 2 to 3 year accreditation process. The government of Botswana has adopted routine HIV testing nationwide. A training manual for rapid HIV testing was developed in FY05 and FY06, and training of 35 master trainers was organized in FY06. In FY07, 200 to 300 lay counselors will be trained (all lay counselors in the VCT centers, TB, and PMTCT programs, and laboratory technicians). A quality control system for rapid HIV testing will also be developed and implemented. 4. Early infant PCR testing. A major focus of the PMTCT program is to reduce transmission of HIV to neonates. In 2005, early infant diagnostic testing was piloted in 2005 by USG and MOH using Dried Blood Spot (DBS) PCR. Training was conducted for sample collection, and a laboratory technician was sent to CDC/Atlanta to be trained in DBS - PCR. At present, only one laboratory (has the capacity to perform the test. In FY06 and FY07, early infant diagnosis using DBS is being rolled out to all of the health care facilities in Botswana. In FY07, a second laboratory with the capability of conducting dried blood spot PCR will be set up in Francistown to cover the northern part of the country. In addition, labsthe two labs will be enrolled in the CDC External Quality Assurance and Proficiency Testing. 5. Improve human capacity. An ongoing challenge for the GOB is a severe shortage of qualified laboratory personnel. Botswana's Institute of Health and Science (IHS) has a three-year diploma program, and is able to train 15 students every 3 years. More than 50% of lab technicians in Botswana are foreigners, and the average number of lab staff is 3 per laboratory. This is low relative to the needs of the labs in the ARV program. In FY07, additional teaching staff and laboratory technicians to support laboratory training will be provided to strengthen the IHS. In addition, laboratory technicians will be hired to increase the capacity at the labs in Francistown, Gabarone, and the National Quality Assurance Lab. 6. Equipment procurement and maintenance. Procurement of laboratory supply, reagents, and equipment is done through the Central Medical Store (CMS). CMS is a government structure responsible for the procurement of all government supplies for offices, labs, and ARV drugs. The procurement and distribution is slow, often not responsive to the end user, and the process is error-prone. Storage of reagents is a concern, as most facilities do not have cold rooms. FY07 funds will be used to assess, develop, and improve the supply chain management at CMS and the National Health Laboratory with the assistance of the Supply Chain Management System. A warehouse with a cold room will be provided to support the Botswana National Health Laboratory (NHL) to ensure that laboratory supplies are kept in good condition.

Program Area Target: Number of tests performed at USG-supported laboratories during the 80,000 reporting period: 1) HIV testing, 2) TB diagnostics, 3) syphilis testing, and 4) HIV disease monitoring Number of laboratories with capacity to perform 1) HIV tests and 2) CD4 tests 14 and/or lymphocyte tests Number of individuals trained in the provision of laboratory-related activities 352

Table 3.3.12:

07-T1201: Ministry of Health.

This activity has USG Team Botswana Internal Reference Number T1201. This activity links to the following: C0705 & C0706 & C0901 & C0902 & C0910 & T1110 & T1111 & T1112 & T1204 & T1205 & T1206.

Activity1: Decentralization of CD4 and VL In FY05 and FY06 the MOH, with the support of ACHAP and EP, decentralized CD4 count testing to a total of 20 laboratories in Botswana. In FY06, VLtesting was decentralized with 2 additional district laboratories bringing the total number of laboratories doing VL testing to four. However, as more patients are enrolled in the ARV treatment program, the demand for VL testing also increases, thus compromising the turn around time. Efforts to decentralize VL testing will continue in FY07. Three additional sites will be developed to perform VL, bringing the total number of laboratories to 7. Also, one additional site will be equipped with a CD4 machine, bringing the total number of CD4 laboratories in the country to 21.

Activity2: QA To support the QA program in the country, a QA laboratory was established using a porta cabin in FY06. In FY07, these efforts will continue by improving the QA laboratory: the lab will be equipped, and training for 2 staff members will be provided. The QA laboratory will develop QA materials needed to review the monitoring of patients (hematology, chemistry, and microbiology including TB), and will develop national laboratory standards for hematology, chemistry, and CD4. FY07 funds will also support the QA Unit to conduct the annual laboratory assessment. The FY07 budget will help strengthen the QA program by enrolling the new CD4 and VL decentralized laboratories in an external quality control program.

Activity3: Laboratory Information System (LIS) In FY06, an assessment was conducted to initiate the development of a LIS. In FY07, LIS software will be developed to improve the monitoring and evaluation (M&E) of people receiving ARV treatment. The system will provide annual statistics and strengthen the National Laboratory Program.

In collaboration with the different sections at MOH involved in the ARV treatment program, a field assessment of the laboratories will be conducted in FY07 by the NHL staff. The information needs will be identified, and software will be developed. Training in the LIS and computers will be provided to the laboratories. A network system will also be considered to facilitate communication between the district and primary hospital laboratories and the NHL.

Activity 4: Rapid HIV test training and procurement rapid HIV test Kit In FY06, 30,000 rapid HIV test kits were provided to support RHT in Botswana. A rapid test training manual was developed, and training for rapid HIV test was conducted for nurses, lay counselors, midwives, and lab techs. In FY07, we will continue supporting RHT. Rapid HIV testing continues to play a key role in identifying HIV infected individuals at VCT centers and other testing facilities. An estimated 210,000 HIV tests are expected to be performed in public health facilities through RHT each year. More than 120,000 people are tested annually through the Tebelopele and other NGO VCT centers.

Scale up of rapid HIV test training for nurses, lay counselors, midwives, and lab techs will be critical to meet these needs. With the introduction of RHT, rapid testing is often performed by non-laboratory personal. In order to ensure the accuracy and quality of the result, training for nurses, lay counselors, midwives, and lab techs will continue during FY07 in all clinics, VCT centers, and hospitals. In addition, a quality control system will be developed.

Activity 5: Revision of the National Guidelines for monitoring VL and CD4 WHO recommends a minimum frequency of laboratory tests for monitoring in resource-limited settings, including CD4 testing at entry into care, at initiation of first-line or second-line ARV regimen, and every six months. VL measurement is not recommended for decision-making on the initiation or regular monitoring of ARV therapy in resource-limited settings. However, the guidelines in Botswana recommend the use of VL

and CD4 count testing of the patient under ARV treatment every three months. In FY07, we will perform an analysis of existing data to determine the usefulness of VL testing in monitoring patients. Workshops will be organized with clinicians and all sectors involved in the monitoring of patients on ARV therapy. Based on the outcome of the workshops and the data analysis, guidelines for laboratory monitoring of patients will be proposed.

07-X1306: MOH-DPPME: ICD-10 Training

This activity has USG Team Botswana Internal Reference Number X1306. This activity links to the following: T1111 & T1112.

The Health Statistics Unit (HSU) is the focal point for all issues relating to health information system in the MOH. It facilitates the data collection, processing, verification, analysis and dissemination of health service data throughout the country. It also coordinates health data sharing with other stakeholders.

The HSU revised its data collection tools in 2004 using the International Classification of Diseases 10th Edition (ICD-10). Currently, the HSU is using the ICD-10 for coding diagnoses for both mortality and morbidity. However, the HSU is faced with a serous shortage of personnel trained in the use of ICD-10. This means majority of the health care workers engaged in making diagnosis and writing statistical reports and/or managing medical records in all of the 35 hospitals around the country are not capable of properly using the ICD-10. USG support in training the HSU staff on ICD-10 will improve identification, collection, and processing of HIS at all levels. Further, it will assist the unit produce timely and accurate health statistics report that can be used for health and social development planning.

Part of these funds will be used to purchase at least one set of ICD-10 reference tools for each hospital in the country.

Therefore, the MOH's DPPME, is requesting EP funds to urgently train all 18 HSU staff in the use of ICD-10. This will allow the office to be effective, efficient, and able to promptly report quality data that meet international standards.

07-X1302: MOH- DHAPC: ANC Sentinel Surveillance 2007.

This activity has USG Team Botswana Internal Reference Number X1302. This activity links to the following: T1111 & T1112 & X1308.

USG has provided financial and technical support to the GOB to conduct ANC sentinel surveillance for HIV prevalence, incidence, and HIV drug resistance among pregnant women for the past 3 years. Data generated by the ANC sentinel surveillance surveys are very important for planning prevention activities in the country, thus timely evaluation of these surveys will be pivotal.

Part of the FY2006 fund for ANC sentinel surveillance was used to procure reagents and supplies for the 2007 ANC sentinel surveillance for HIV among pregnant women. FY07 funding for this activity will therefore be lower than it used to be in the previous years.

The requested FY07 funding will support the transportation of blood specimens, printing of the 2007 ANC sentinel surveillance reports, development of flyers and posters, and dissemination of the 2007 ANC sentinel surveillance report.

The surveillance unit at MOH/DAPC has an acute shortage of technical staff, thus limiting its ability to adequately conduct the ANC sentinel surveillance. This problem is addressed in activity X1308 during FY07.

07-X1304: MOH-DHAPC: Assessing the utility of PMTCT program data for HIV surveillance.

This activity has USG Team Botswana Internal Reference Number X1304. This activity links to the following: P0101 & P0107.

In most countries, the heart of HIV surveillance is unlinked anonymous testing (UAT) of leftover blood collected during routine care for pregnant women. UAT assures minimal participation bias, as ANC attendees typically are not aware of this activity. In contrast, HIV testing for PMTCT is based on informed consent, applying the principles of VCT or routinely recommended testing. In Botswana, the acceptance of PMTCT-related HIV testing varies by district, and can range from 75% to 97% in 2005, with a national average of 83.2%. Studies among pregnant women and other HIV testing populations show that those who accept or refuse HIV testing often differ in their risk factors for HIV and/or their HIV status, leading to potentially biased survey results as compared to those relying on UAT. Given that the PMTCT program is provided in all ANC sites in Botswana, PMTCT data may increasingly be used for surveillance. In addition, as UAT has no direct benefit for the sampled woman, UAT has been questioned ethically, and may be discontinued in favour of name-based testing for PMTCT. However, little is known about the comparability of PMTCT data to ANC-based UAT surveillance data. This is because PMTCT data are generally reported on an aggregated basis, and the availability, accessibility, and quality of on-site PMTCT line-listing data are often uncertain.

The general objective of this evaluation is to investigate the utility of PMTCT data for HIV surveillance and to describe PMTCT-related selection biases. Another objective is to evaluate the utility of same-site UAT data for monitoring and evaluation of PMTCT programs.

Data collection will be mainly retrospective. For analysis, line-listing UAT data will be used for surveillance; for PMTCT, line-listing data is preferred but where unavailable, aggregated data may be used. HIV prevalence rates in the UAT surveillance group will be compared to those in the PMTCT group at site, district, and country level. Determinants for HIV-infection will be compared in both groups, and possible adjustment factors will be evaluated.

This targeted evaluation is part of the global evaluation of the utility of the PMTCT data in HIV surveillance. A survey protocol is currently under review by GAP Atlanta and the MOH's HRDC.

07-X1401 MOH Human Resource Development

This activity has USG Team Botswana Internal Reference Number X1401. This activity links to the following: X1410 & X1411 & X1412 & X1415 & X1490.

This project began in 2004 as part of the Southern Africa Capacity Initiative with initial financial support from UNDP and technical assistance from both UNDP and WHO. In 2005, EP provided funding for an assessment of human resources and health service, resulting in a revised human resource plan that takes into account the HIV/AIDS epidemic and the Government of Botswana's (GOB) response. The assessment, however, revealed major inequities in the magnitude and distribution of health services. These inequities, exacerbated by the recent and rapid expansion of national HIV/AIDS prevention, care and treatment services by the Government, have led to an urgent need for the development of an integrated service delivery framework that will make possible the implementation of quality health programs.

In 2006, EP provided funding to MOH's Department of Policy, Planning, Monitoring and Evaluation (DPPME) to undertake this next phase of the project. The overall purpose of the current three-year activity is to develop an integrated service plan and framework to enable the health sector in Botswana to cope with changes in workload brought about by the HIV/AIDS pandemic, to rectify inequities in service delivery and to improve quality health care. DPPME is a new department in the MOH and as such is currently experiencing huge capacity shortages. Therefore it will be critical that the process used to implement the project develops the capacity of the MOH. Management processes at major health care delivery institutions will also be strengthened to enable active participation in service delivery planning.

With an ultimate aim of providing appropriate and equitable access to all levels of service for the general population, an integrated national framework and plan will provide: • A national overview of the current status of service provision. • A detailed assessment of actual service requirements through analysis of patient/case referrals and services offered. • A service configuration plan that is affordable and sustainable and that ensures that resource use is effective and efficient. • A basis for a long term vision to enable integration of key initiatives (such as capital development and equitable human resource distribution); aspects that can be implemented only over extended time frames. • A basis for ensuring (1) that all levels of service delivery are addressed, and (2) that primary health care and hospital care are integrated. • A rational basis for addressing health needs and national health priorities in a resource-constrained environment. The health service delivery framework will guide the provision of accessible, affordable, and equitable health services to the population of Botswana. The framework will include service delivery standards and facilitating policies and will be used to realign the type, number and location of health facilities in Botswana, the magnitude of services that should be rendered and the optimum mix of resources needed.

During the first year (2006), a national essential package of services is being developed, the referral network restructured, and skills of facility managers strengthened to enable them to increase effectiveness and efficiency levels and manage appropriate health service delivery within their institutions. During fiscal year 2007 (FY07, October 2006-September 2007), a computerized personnel administration system will be put in place in 28 hospitals and a staff development/training plan and hospital management toolkit and procedure manual developed. A sub-contractor will be engaged to work within MOH to build capacity of local staff while implementing this phase of the project. National and district health staff will be engaged in the development of the training plan, toolkit and procedure manual through a series of consultative meetings and workshops. Capacity building at institutional level will be a major component of the process.

The funding for this activity was reduced for COP 07 because of delays in implementation in years one and two and a large carryover of funds.

07-X1415: Ministry of Health, Department of Ministry Management.

This activity has USG Team Botswana Internal Reference Number X1415. This activity links to the following: X1401 & X1411 & X1412 & X1490.

Since 2003, EP has supported the strengthening of pre-service training in PMTCT for nurses and allied health professionals with technical assistance from the UMDNJ 's FXBC. In 2007, this activity will be broadened to include strengthening of all HIV/AIDS pre-service education. The overall aim of the twinning activity is to ensure high-quality pre-service training in HIV/AIDS by providing faculty with cutting-edge HIV/AIDS-related information, incorporating this information into curricula and making HIV/AIDS-related resources and information available to students. As part of this capacity building, FXBC works with and through the MOH HIV Training Coordinator who is responsible for all HIV training, course content and staff development. In 2007, the coordinator, who is funded by EP under the PMTCT program, will implement a number of activities to complement the technical assistance provided by the FXBC twinning program. These include regular update workshops to keep faculty abreast of Government of Botswana HIV/AIDS programs and their implementation; development of new courses on HIV/AIDS: 1) a basic HIV/AIDS course for entry level students, and 2) a course focusing on the social dimensions of the epidemic, and; the implementation of workplace programs for both faculty and students at the health training institutes.

This EP activity was previously funded under PMTCT.

The impact of HIV/AIDS on Botswana's healthcare system, coupled with health workforce shortages, has created substantial increases in the physical and emotional demands faced by health workers. Throughout the epidemic, health workers have been in the forefront of care and prevention activities, managing greatly increased numbers of severely ill patients and assuming new responsibilities for PMTCT services and more recently, antiretroviral (ARV) treatment. At the same time, it has become more difficult to respond to the demands of work, since many health workers themselves are HIV infected or are personally affected through ill family members or friends. Though in the forefront of the epidemic, many health workers are the last to seek treatment and care services and are both victims and perpetrators of stigma and discrimination.

GOB seeks to ensure that the present and future health workforce is able to cope with the demands of the epidemic and effectively perform its duties. To achieve this aim, the MOH, with EP support in 2005, implemented a needs assessment to obtain input from health workers in order to inform and guide the development of a National Wellness for Health Workers Programme. The study objectives were: • To determine the magnitude, sources and indicators of stress among health workers. • To identify strategies used by health workers to cope with work-related stress. • To determine counseling and psychosocial support needs of health workers. • To ascertain health worker preferences for delivery of psychosocial support services. • To make recommendations to the Ministry of Health on the establishment of a National Wellness for Health Workers Programme.

In late 2006, the University of Medicine and Dentistry of New Jersey - François-Xavier Bagnoud Center (FXBC) was tasked by the MOH and BOTUSA to assist analyzing the data. The findings of the report clearly substantiate the need for a National Wellness for Health Workers Program in Botswana but also identify challenges that must be addressed to ensure that such an initiative is effective and accessible. The goal of the National Wellness Program is to provide services and support opportunities to enhance the well-being and job satisfaction of health workers in order to improve their emotional and physical health, prevent burnout, enhance staff retention, and have a positive impact on patient care. This program is expected to increase health worker knowledge of HIV/AIDS, improve access to services and reduce stigma and discrimination.

The MOH is spearheading this program with partial funding from PEPFAR (2006 funds under counseling and testing) and technical support from FXBC. To date, a national steering committee has been formed, district managers briefed, an assessment of the hospitals conducted, a study tour undertaken, a three-year implementation plan and a marketing brochure developed.

This activity will provide funding directly to the MOH for the following activities: 1) Development, printing and dissemination/training of wellness program guidelines, 2) Program launch, 3) Printing of training manuals being developed by FXBC, 4) Training of Trainers in the use of the manuals, and 5) Development of promotional materials.