P0107 I-TECH Data quality improvement

This activity is has USG Team Botswana Internal Reference Number P0107. This activity links to the following: P0102 & P0104 & X1301 & X1303 & X1304.

In 2005, through USG support, the HHS/CDC/BOTUSA completed the development of a computerized PMTCT monitoring system and installed it at the national PMTCT offices in the MOH. This system, based in Epi-Info, was to be rolled out to the districts in FY06 to improve the capacity for monitoring PMTCT program implementation and quality of care. In anticipation of the roll out of the system, HHS/CDC/BOTUSA trained 24 PMTCT focal persons and Peace Corps Volunteers (PCVs) in M&E. However, due to critical human resource shortages at the MOH, including the absence of a data manager, the rollout was suspended. The absence of a data manager also resulted in a lack of supervision and guidance on data entry into the database at the MOH, as well as on data collection at the clinic level. Overall, this resulted in a lack of reliable data for PMTCT program monitoring, and for policy making and guidance.

This new activity is intended to improve human capacity and quality of data relating to PMTCT, with the emphasis areas of strategic information, human resources and local organization capacity building.

The first component of this activity will be to hire and second to MOH a data analyst, a data manager, and two data clerks as follows:

Systems Analyst (1) Grade: International contractor position Salary and benefits: $62,500 Justification for the Position The data analyst will be placed at the MOH PMTCT unit to help in managing and ensuring improved data quality. The data analyst will ensure the database is fully functional, and that data are being correctly entered and analyzed, and feedback is being given to the districts and health facilities.

Data Manager (1): Grade: D4 @$27,500 per annum = salary + benefits, Justification for the Position This position will supervise two data clerks and be responsible for the PMTCT information system, M&E. The position is stationed in Gaborone at the Gaborone PMTCT Main Office.

Data Clerk (1): Grade B2 @US$ 6000 =salary and benefits Justification for the Position The data clerk position will do data entry, cleaning and storage under the supervision of the Data Manager. The position is stationed in Gaborone at the Statistics Office. Second, in collaboration with the entire PMTCT team, I-TECH will provide ongoing mentoring and team building among the national PMTCT M&E team. In addition, I-TECH will assist the program to establish mechanisms and procedures for data quality control, and take necessary steps to ensure data reliability. This component will compliment the Botswana government's effort in building human resource capacity to manage the PMTCT program both at the national and district levels.

Third, I-TECH will conduct an assessment of data quality to identify the causes and gaps in completeness of data collected at the facility level, and data aggregated at the district level. Complete, accurate, and timely data are critical in M&E the PMTCT program. I-TECH will provide technical support to the PMTCT program to conduct an assessment of data quality in selected districts and clinics to assess the validity of at least 25% of the data reported by providers on selected key PMTCT indicators and required program-level EP indicators. Fourth, I-TECH will train master trainers who will in turn train health providers to appreciate the need for completeness of data, to analyze and use data locally, and to send relevant data to the central level.

Key Functions for I-Tech: •Review the job descriptions with the relevant departments •Advertise and hire Systems analyst internationally, and a data manager and a data clerk through local human resource company •Provide technical support to the employee where applicable trough the in-country I-Tech office •Administrative support •Conduct staff appraisals in conjunction with MOH •Establish memorandum of understanding with MOH to guarantee that the positions are accepted and sustained after EP funding ends.

A portion of these funds will cover technical assistance and management costs for ITech in-country.

P0502: HIV Prevention Needs Assessment of Female Sex Work. This activity links with P0509.

The assessment will identify needs relevant to HIV prevention programs for female sex workers (FSW) in the following 6 field sites: Francistown, Gaborone, Ghanzi, Kasane, Letlhakane and Selebi-Phikwe. Open-ended in-depth interviews (IDI) or focus group discussions (FGD) and a brief close-ended demographic survey will be used to collect data from a maximum of 80 interviewees and a maximum of 96 discussants.

The first stage of the assessment will consist of phone calls to 4-10 non-governmental, community-based and faith based organizations (NGOs/CBOs/FBOs) that provide programs for women in the 6 field sites to collect summaries of their organization, activities and estimated reach. NGOs/CBOs/FBOs recognized for their work with vulnerable women, particularly with regard to violence, substance use and other health issues, will also be engaged even if they are not in the 6 field sites.

In the second stage, 2-3 NGO/CBO/FBO heads or their designee in each field site will be interviewed about their perceptions of challenges faced by women, the programs available to them, the strengths and weakness of existing programs and recommendations for further action with regard to FSW. NGOs/CBOs/FBOs will be asked to update a brief form that lists the various organizations that work with women in their geographical area. Two HCWs and two traditional/spiritual healers in all field sites (except Gaborone and Francistown as explained below) will be interviewed on the problems for which women seek help, the services they receive and any insights that they might have with regard to gaps in services for FSWs. Up to six FSWs will be interviewed on activities they engage in before, during, and after sex work. These will include substance use, violence, payment issues, and sexual behavior. One FGD with 4-8 men identified in naturally occurring groups in bars or social clubs and organized with the help of previous Men, Sex and HIV/AIDS program employees will be conducted in each site. The FGDs will explore male perceptions and attitudes towards FSWs, the reasons why men engage in commercial and unprotected sex, the perceived risks and benefits of such engagement and possible measures to reduce the potential risk.

The results will then be disseminated broadly, to stimulate feedback and discussion about the results and recommendations.

07-C0609: University of Pennsylvania.

This activity has USG Team Botswana Internal Reference Number C0609. This activity links to the following: C0613 & C0614 & C0616 & C0703 & C0814 & T1111 & T1112 & T1115.

Continuing Medical Education (CME) Lectures in Gaborone UPenn specialists will provide continuing education lectures for physicians, nurses, pharmacists, and other health care providers in the Gaborone area. UPenn will provide education through these teaching conferences to 20 or more providers attending each of these sessions, held every 3-4 months throughout the year.

Implementation of the National Guidelines for HIV-related Palliative Care UPenn specialists will help implement guidelines for the palliative care of PLWHA. UPenn physicians will continue to collaborate with the MOH PCU and participate in the rollout of the palliative care guidelines. UPenn will continue to participate in implementing guidelines for palliative care throughout the year.

The UPenn program in Francistown began in November 2005. In FY07, they will continue to have two UPenn Specialists working in Francistown. They will divide their time equally between NGH and outreach.

Activity 2: NRH The NRH component will be designed in collaboration with the Superintendent, and will include inpatient and outpatient care, training, curriculum development and didactic teaching. FY07 outcomes at NRH include: (a) provision of clinical, psychosocial, and social palliative care to about 600 HIV inpatients (non-TB) at NRH. (b) provision of care to 180 outpatients newly started on ART. (c) provision of outpatient care to 1,000 outpatients maintained on ART. Note that many of these patients will also be seen by other providers over the course of a year since return visits are not directed to any one physician. Therefore, these are not unique patient visits, but are the total number of patients seen over the course of a year who are on ART. (d) provision of indirect palliative care to approximately 1,000 HIV patients through interactions with other providers at NRH. (e) provision of training to approximately 20 physicians, nurses, and nursing students employed by NRH who round with the UPENN specialists during the year. This teaching will be in the form of bedside teaching during daily rounds.

Outreach Program One specialist will spend 2-week periods at each of several locations including Tutume and Masunga. At outreach sites, the UPenn specialist will be involved in inpatient consultations, outpatient consultations, one-on-one mentoring, and classroom lectures. In addition, UPenn specialists will continue to provide consultation by phone to physicians in the area. UPenn will provide direct consultation and palliative care to approximately 200 inpatients without active TB, 70 inpatients with active TB, and 1,000 outpatients who were previously started on ART. UPenn will provide phone consultation to advise on care of approximately 300 patients during the fiscal year.

Educational Programs at NRH UPenn providers will continue to direct intake rounds Monday through Friday each week; daily ward rounds serve as one of the main teaching conferences for the interns and medical officers. In addition, UPenn staff will continue to organize both a weekly didactic lecture series and HIV conferences for interns, medical officers, and other healthcare providers at NRH. UPenn will provide education through these teaching conferences to 20 individuals attending sessions at NRH over the course of the year, and 40 individuals at outreach sites.

Implementation of the National Guidelines for HIV-related Palliative Care UPenn specialists will help implement guidelines for palliative care of PLWHA at NRH as described above.

07-C0610: I-Tech-STI Syndromic Management.

This activity has USG Team Botswana Internal Reference Number C0610. This activity links to the following: C0611 & C0613 & C0614 & C0902 & C0910.

In 2005, International Teaching and Education Center on HIV (I-TECH) successfully implemented sexually transmitted infections (STI) training, including the introduction of acyclovir for genital ulcer disease, in Lobatse and Chobe (phase I districts of implementation). In 2006 training was rolled out to an additional 10 sites (phase II districts). Training in syndromic management of STIs includes routine HIV testing (RHT) of clients as well as risk reduction counseling.

In FY07, building upon the FY05 and FY06 activities, I-TECH will expand supportive supervision visits to phase III district health facilities as a follow up to the STI syndromic management training that these health care providers (HCPs) received in 2005-2006 and continue to support supervision activities in phase II districts. The supportive supervision training that was developed and offered to district trainers in phase I and II districts in 2006 will be repeated for phase III districts.

FY07 funds will continue to support the STI/M&E trainer (hired with 2006 funds) who will support the district trainers in their efforts to plan supportive supervision visits, respond to efforts to improve the quality of care, and report on the visits. I-TECH plans to conduct a three-day Training of Trainers from the phase III districts, hold a one-day sensitization workshop for district supervisors on the supportive supervision/clinical mentoring activities, and provide for partial training and participant costs that will be shared with the MOH.

FY07 funds will be used to hire a data manager for the MOH National STI Training and Research Center (NSTRC). This position will take the lead in data collection, monitoring, analyzing, and reporting on the data. In addition, I-TECH will provide technical assistance to the NSTRC on integrating their monitoring activities into the MOH's overall M&E and surveillance activities. The targeted population includes the primary health care physicians, nurses, and other health workers. The STI/M&E trainer will work with the NSTRC coordinator and clinic staff, administration, Central Medical Stores (CMS), and other stakeholders to improve the quality of STI care. As the supervision and reporting expands, the EP-funded data clerk who tracked prescription of acyclovir in Chobe and Lobatse (phase I districts) and STI syndromic management trainings in 2006 will take on the responsibilities for tracking acyclovir data from both phase I and phase II districts and entering data from the supervision visits in 2007.

FY07 funds will be used to support the time and travel of the I-TECH M&E Lead and the I-TECH STI/HIV Clinical Mentor to conduct the training of phase III district trainers on supportive supervision/clinical mentoring. The I-TECH M&E Lead will also provide technical assistance to the NSTRC in reporting the results of the supervision visits and integrating them into the MOH activities. EP funding will support the time and travel of the I-TECH data manager to assess the data management needs of the NSTRC, assist with hiring data staff, and developing and training on an appropriate database.

EP funds under this activity will also support a portion of overall I-TECH country management and technical assistance costs.

07-C0618: NGO supporting organization in the North.

This activity has USG Team Botswana Internal Reference Number C0618. This activity links to the following: C0602 & C0603 & C0604 & C0605 & C0606 & C0607 & C0608 & C0613 & C0804 & C0805 & C0806 & C0807 & C0808 & C0810 & X1406.

The objective of this activity is to strengthen the HIV/AIDS civil sector response in Botswana especially in the northern area of the country, an area not covered by any of the Pact grantees. An organization will be identified to support NGOs to increase their service population and improve the quality of their interventions. This organization will assess the comprehensive palliative care needs in these underserved areas, and work to meet those needs in alignment with the goals outlined by EP and the 5 Year Strategic Plan.

In FY07, five local organizations will receive financial and technical support to improve their implementation of palliative care programs. The funds will be used to provide grants and promote programs for PLWHA in areas such as service delivery, equipment, material development, and needs assessment. This will strengthen the clinical, social, spiritual, and psychosocial aspects of palliative care.

The five organizations will be encouraged to network and create linkages with other organizations providing palliative care and other relevant partners. In addition, these organizations will work closely with the MOH PCU to ensure compliance with the national guidelines and other policy frameworks. The organizations will also be guided by the minimum essential package defined by the Ministry in providing services to PLWHA at the household and community levels.

The organizations will also collaborate with other relevant government ministries such as the MOE, MLG and the MOH nutrition rehabilitation project for malnourished OVC affected by HIV/AIDS. Where applicable, the organizations will utilize existing national training manuals on palliative care.

These grantee organizations will be monitored by the technical assistance partner (TBD) to ensure provision of quality services to PLWHA. They will also participate in tracking data that is necessary in responding to M&E needs at MOH.

07-C0619: I-Tech-Opportunistic Infection Training.

This activity has USG Team Botswana Internal Reference Number C0619. This activity links to the following: C0603 & C0703.

In FY07, I-TECH will provide technical assistance to the UPenn to generate clinical palliative care guidelines and a training curriculum for health care providers in the palliative care portion of their program, specifically OIs in HIV patients. These guidelines and training curriculum will be developed in collaboration with the MOH PCU, and will complement existing guidelines on OIs. Utilizing the I-TECH 5-Level Training Framework, I-TECH will support UPenn in building a structure to purposefully develop capacity among health care professionals in Botswana to deliver quality HIV care. As part of this effort, I-TECH will work with UPenn using the I-TECH Clinical Mentoring Toolkit to develop a palliative care curriculum, and then use the curriculum to train Botswana health care providers. The curriculum will be adapted to the Botswana context from previously developed HIV/OI curricula.

07-C0703 U. of Pennsylvania

This activity has USG Team Botswana Internal Reference Number C0703. This activity links to the following: C0609 & C0613 & C0619 & C0701 & C0704 & T1111 & T1120.

TB is endemic in sub-Saharan Africa, but because of the burgeoning HIV epidemic, its epidemiology and clinical impact have been dramatically altered. HIV infection leads to progressive immune deficiency and increased susceptibility to a variety of infectious agents including TB. HIV infection has significant and complex interactions with TB disease with relation to many clinical issues and the same has been demonstrated for TB's effect on HIV/AIDS.

More than 10,000 TB cases have been reported in Botswana annually since 2001. This dramatic increase has been attributed to the effects of the HIV epidemic. Given the clinical and programmatic challenges presented by TB/HIV co-infection, existing services may be ill-prepared to handle the special and at times complex issues raised by TB/HIV co-infection, such as atypical clinical presentations, drug-drug interactions/toxicities and sequencing of anti-TB and antiretroviral therapy. In order to address the clinical challenges posed by TB in HIV-infected persons, we have begun a TB-HIV Clinical Initiative which provides palliative care and anti-retroviral treatment to co-infected PLWHAs, and training to local providers responsible for the clinical management of such patients. Within the first quarter of the year, we provided care to nearly 100 co-infected persons at an HIV clinic located in the capital of Gaborone and have instructed more than 50 local providers throughout the city. During the next fiscal year we seek to enhance the training and preceptorship program with the goal of strengthening the local human capacity to manage issues related to these two diseases. This will be accomplished through close partnerships and linkages with both the BNTP and International Training and Education Center on HIV (I-TECH).

Activity 1: Enhanced TB/HIV training and mentoring program. Emphasis area: training, quality assurance and supportive supervision

We seek to establish a close partnership with the BNTP to develop an enhanced training program focusing on the clinical management of TB for the HIV-infected individual. It is estimated that more than 60-86% of TB patients in Botswana are co-infected with HIV, but to date, limited training exists for HCW to familiarize them with evolving national ARV treatment guidelines related to TB and to provide training and assistance for the clinical management of TB-HIV co-infection.

A University of Pennsylvania (UPENN) supervising physician will work closely with two I-TECH trainers at the BNTP/MOH to lead the training of clinicians. The target audience will be public doctors and nurses at the primary district and referral level health facilities. The focus in 2007 will be in the greater Gaborone area with initial training sites including Mochudi, Molepolole, Ramotswa, Kanye and Lobatse, as well as the referral hospitals in Gaborone and Francistown. The plan will be to expand the training throughout the country as future funds allow. Training will be conducted at the specific health facilities using a combination of didactic and interactive methods, such as case workshops, rounding and clinical mentoring. As a supplement to the initial training, UPenn will establish a local preceptorship system whereby a faculty facilitator will visit health facilities and provide clinical mentorship to local providers working with co-infected patients in order to enhance and strengthen the training received during the initial meetings.

This activity is integrated with the TB/HIV training activity of I-TECH in that I-TECH will be hiring and supervising two dedicated trainers at the BNTP/MOH, developing the curriculum based on their five-level training framework, and providing a part-time training coordinator to assist UPenn with the training plan. 2007 EP funds are requested to support the preceptorship personnel (a full-time physician and nurse), and local travel, and related instructional materials.

Activity 2: Palliative care and consultation for TB-HIV patients

We will continue to work at Princess Marina Hospital (PMH), the main referral health facility in Gaborone to address complex clinical issues related to TB-HIV co-infection

through clinical consultation and both indirect and direct patient care. This is a referral-based system whereby local providers can seek direct assistance from clinical experts in the care of HIV-infected patients with TB.

07-C0704: ITECH TB/HIV.

This activity has USG Team Botswana Internal Reference Number C0704. This activity links to the following: C0613 & C0701 & C0703 & T1111.

Activity 1: Capacity Building of health care providers on the co-morbidities of TB and HIV. Emphasis area: training, quality assurance and supportive supervision

For 2007, with some activities starting in 2006, I-TECH has been requested to support the UPenn in building the skills of Botswana health care providers on the care of HIV patients co-infected with TB. Utilizing the I-TECH 5-Level Training Framework, didactic training, skill building workshops, clinical training, clinical consultation, and technical assistance, I-TECH will support in building a structure for UPenn's clinical program to purposefully and incrementally develop capacity among Botswana health care providers to manage the clinical complexity of TB-HIV co-infection. This structure will provide steps to lead health care providers from increased knowledge, to building skills, to receiving support to change practice that would fit newly learned skills and knowledge, to having access to more advanced consultation in support of new practice, and, finally, technical assistance in system level changes that may be needed.

As part of this effort, I-TECH will recruit, hire, train, and supervise two dedicated Botswana trainers to work with a UPenn clinician who will train and mentor Botswana clinicians using the I-TECH Clinical Mentoring Toolkit. In collaboration with BNTP and UPenn, I-TECH will develop TB-HIV care curriculum based on Botswana national guidelines and adapting existing resources such as the WHO's IMAI (spell out) curriculum, HHS/CDC curricula and I-TECH/Namibia TB-HIV training curriculum. The curriculum will include TB diagnosis, TB prevention and infection control, complexities of clinical management, Anti Tuberculosis Treatment (ATT)/ARV drug-drug interactions/toxicities and sequencing, and multi-drug resistant tuberculosis disease. There will be two separate curricula - one for physicians and one for nurses. Each curriculum will consist of a set of presentation slides, a Facilitator Guide, and a Participant Handbook. After the preliminary curriculum is developed by the I-TECH Health Communication Team, it will be reviewed by the appropriate content experts. Once reviewed, the curriculum will be sent to a Botswana Reference Committee of local stakeholders which would include representatives from BNTP, UPenn, and HHS/CDC/BOTUSA for final approval. The curriculum for classroom training will include a pre test and post test with case studies about hypothetical patients that highlight key elements of TB diagnosis and treatment for people with HIV. The curriculum for clinical training will include an observation checklist by which a mentor may evaluate clinical skills of participants.

The above activity is in support of UPenn TB-HIV training and clinical mentoring program which provides the clinical educator expertise, conducting training, reviewing and approving curriculum, and providing introduction to and relationship with clinics and practicing Botswana clinicians.

EP funds are requested to support a half-time in-country training coordinator who will oversee this process, two dedicated trainers, and the curriculum development team.

Activity 2: Strengthening of TB-HIV program linkages. Emphasis Area: Development of Network/Linkages/Referral Systems Background: There is a need to review TB case detection among PLWHAs and to improve referral to care and treatment for ARV and TB patients. Currently, when patients are referred, there is no systematic way of tracking their treatment or progress.

In collaboration with the UPenn, we seek to build on relationships with the MOH and BNTP, and MASA to conduct a needs assessment of the referral system for TB patients to gain access to ARVs at the health facilities and TB screening for HIV patients at infectious disease clinics (IDCCs). I-TECH will design and conduct the assessment to be conducted at 2-3 IDCCs and 2-3 TB clinics (without IDCCs) in each of 6 districts. The assessment will include 5 activities: 1) interviews on health-care-seeking behavior of 20 patients at each clinic, 2) provider interviews, 3) rounding with providers to observer patient flow and referral mechanisms, 4) assessment of laboratory testing and review processes, and 5) analysis of service statistics, laboratory records, and pharmacy records. The assessment

will document how such referrals are made, current success rates of such referrals, and recommend strategies to improve the links between the HIV and TB treatment programs in Botswana. ITECH will provide technical assistance to the MOH and will work with BNTP and MASA programs to establish protocols for screening patients on ARV for active TB disease and to ensure that referral mechanisms are in place to link them with appropriate TB care. They will also work with BNTP to ensure that all TB patients newly diagnosed with HIV are referred to HIV care and treatment. Outcomes will include recommended Standard Operating Procedures for screening and referral. 2007 EP funding is requested for the salary, lodging and per diem, international and local travel costs for an expert consultant to spend eight weeks in Botswana conducting the evaluation working with a local program management team including a team supervisor, two local interviewers, a laboratory specialist, and two data entry support personnel. Partial Full Time Equivalent (FTE) of the I-TECH M&E Specialist to do the research design and data analysis will also be supported with these funds.

A portion of these funds will cover technical assistance and management costs for ITech in-country.

Additional plus-up funds ($170,000) will be used to harmonize the training curricula by incorporating pediatric aspects of HIV/TB care in order to improve the prevention and management of pediatric HIV/TB disease. Funding will be used to support the training of medical and nursing officers at primary and district level hospitals to improve HIV/TB management in children.

07-C0706: ITECH HR development for strengthening lab capacity.

This activity has USG Team Botswana Internal Reference Number C0706. This activity links to the following: C0705 & T1201 & T1206.

I-TECH will help recruit 2 staff persons for the NTRL in Gaborone. Shortage of staff at the NTRL is an obstacle for quality assurance/quality control (QA/QC) implementation and rolling out of the QA program in the country; FY07 funds will help hire 2 TB laboratory technicians to support the TB QA/QC program as well as the routine testing in the laboratory.

2 Laboratory Technicians for the NTRL Annual salary: US $ 48,000 (including benefits)

Justification for position Laboratory technicians will be in charge of TB microscopy, TB culture, perform training in the field for the proficiency testing, and will also be in charge of the quality assurance system in the National TB Reference Laboratory.

A portion of these funds will cover technical assistance and management costs for ITech in-country.

07-T1103: I-TECH.

This activity has USG Team Botswana Internal Reference Number T1103. This activity links to the following: T1102 & T1111 & T1112.

Conducting CMEs

In June 2005, University of Washington's I-TECH was requested by HHS/CDC/BOTUSA to provide a clinical HIV/AIDS expert to work with KITSO, Botswana's national HIV/AIDS training program, on advanced HIV/AIDS topics, particularly ARV drug resistance issues. Since then, I-TECH has collaborated with the MOH, KITSO, and HHS/CDC/BOTUSA by providing an expert clinical trainer to conduct this training four times. Approximately 75 public and private physicians were trained per session on topics such as ARV resistance, salvage highly active antiretroviral therapy (HAART) regimens, and neurological complications of HIV. Thus, in total, the trainings reached some 300 physicians.

In FY07, the scope of work will include four one-week training sessions in Botswana for the I-TECH expert clinical trainer. The topic of training will be advanced HIV/AIDS treatment issues, to be identified in consultation with KITSO and HHS/CDC/BOTUSA. The trainings will be both didactic and skill-building workshops and will be at levels I and II of the five I-TECH levels of training. During each week of trainings, the clinician trainer will work with a KITSO co-facilitator to conduct several hours of lecture, some facilitation of other sessions, and technical assistance to the KITSO team as identified. Specific training objectives will be developed prior to each training in coordination with HHS/CDC/BOTUSA and KITSO, to ensure optimal trainings for specific topics and audiences identified.

Quality Assurance (QA) Evaluation of Harvard Master Trainer Program and QA Training of Harvard Master Trainers: QA and Supportive Supervision, Training

The Harvard School of Public Health has been conducting training of Master Trainers using a team consisting of a physician, a nurse and a pharmacist at each ARV treatment site throughout Botswana. In FY07, USG funds will engage I-TECH to perform a QA assessment of this training, as well as to conduct a Training of Master Trainers (TOT) on how to do QA of their training programs. I-TECH will bring to this activity an assessment team consisting of one M&E specialist and one clinical expert, and a curriculum development team as well as materials that can be adapted to the Botswana context.

The assessment team will conduct a number of visits to Botswana:

1. The team will make an initial visit to Botswana to assess the training and existing measures of QA and improvement. The data from this visit will be analyzed and compared with existing QA data and systems, best practices internationally, and with existing Botswana training standards. Then the assessment team will draw up a plan and outline a curriculum to address any gaps. 2. The team will return to Botswana to present the plan to Harvard, HHS/CDC/BOTUSA, and local stakeholders, and make revisions based on their input. The I-TECH curriculum development team will develop the QA TOT curriculum. 3. Finally, the team will make a third trip, for two weeks, to conduct the TOT for all 32 teams of Master Trainers. 4. After completion of the TOT, the M&E specialist will return to Botswana to monitor the implementation of the QA for training practices and provide support. 5. One last trip for the team will be to assess the implementation of QA for the training system, and to write and present the final report to stakeholders.

HIV/AIDS Treatment/ARV Services: Continuing Medical Education Training

In 2007, I-TECH will also perform an independent evaluation of the AFA CME program (as described above under T1102: Associated Fund Administrators). EP funds in 2007 will support the I-TECH clinical trainer, a program evaluator, training materials, and training site logistics.

These funds will cover a portion of overall I-TECH country management and administrative costs as well as

technical assistance and management costs for I-TECH in-country.

07-T1120: UPENN.

This activity links to the following: C0613 & C0616 & C0703 & T1111.

The scope and direction of the University of Pennsylvania-Botswana program (UPenn) continues to evolve as it enters the 4th year of EP funding. In 2003, UPenn deployed one Botswana-based faculty member at PMH in Gaborone, and now the program has expanded to include the Nyangabgwe Referral Hospital (NRH) in the north. Effective September 1, 2006 UPenn will have 5 medical specialists based in Botswana providing general HIV palliative care and training (3 in Gaborone and 2 in Francistown). In addition, Penn will support 1 physician assigned to PMH totally independent of EP funding whose roll will be to oversee the work of the Penn medical students at PMH.

This has increased Penn's capacity to integrate its contributions into the local health system and more effectively build local healthcare capacity. In addition, UPenn has applied a public health approach to their work by starting a robust outreach program to numerous surrounding district hospitals. Current and proposed sites for FY06 include Lobatse, Ramotswa, Kanye, Molepolole, Mochudi, Tutume, and Masunga. In FY07, using FY06 funds the goal will be to deepen and strengthen activities at each of the current sites rather than adding any new additional activities. The scope of work for the PMH program, the NRH program, and outreach programs follows.

In FY07, UPenn will continue to have 3 specialists staffing the PMH and outreach programs. The plan is to have 1 provider serving as ward specialist at PMH, and 2 providers performing outreach. Activity 1: PMH The PMH component will continue to be designed in collaboration with the Superintendent and Assistant Superintendent at PMH, and will include inpatient and outpatient care, training, curriculum development, and didactic teaching. In FY07, outcomes for the PMH program (these numbers include patients seen by the faculty member hired by Penn to work at PMH) include: a) The total annual number of patients provided with clinical, psychosocial, and social palliative care is estimated to be 500. b) We expect to provide care to 150 outpatients newly started on ARV therapy. c) We expect to provide outpatient care to 1,500 outpatients maintained on ARV therapy. Note that many of these HIV infected patients will also be seen by other providers over the course of a year since return visits are not directed to any one physician. Therefore, these are not unique patient visits, but are the total number of patients seen over the course of a year who are on ARV Therapy. d) We expect to provide indirect palliative care to approximately 1,200 HIV patients through interactions with other providers at PMH. e) We expect to provide training to approximately 30 physicians, nurses, and nursing students employed by PMH who round with the PENN specialists during the year. This teaching will be in the form of bedside teaching during daily rounds as well as didactic and interactive conferences. Outreach Program The continued goal is for 2 specialists to spend periods of 2 consecutive weeks at each of several locations. The current sites include Kanye, Lobatse, Ramotswe, Mochudi and Molepolole. At outreach sites, Penn specialists will be involved in inpatient consultations, outpatient consultations, one-on-one mentoring of health care providers, and classroom lectures. UPenn expects to provide consultation and direct palliative care to approximately 500 inpatients without active TB, 150 inpatients with active TB, and 2,000 outpatients who were previously started on ARV Therapy. Educational Programs at PMH UPENN specialists teach at 4 weekly conferences at PMH, including daily (Mon-Fri) intake reports, a weekly didactic conference on a topic related to inpatient care, a weekly clinical conference, and an HIV journal club that sponsored jointly with the Baylor group. The targets for these teaching conferences are the interns and medical officers assigned to PMH. In addition, research personnel from Harvard, Penn, and Baylor programs are encouraged to attend the weekly journal club. This program is ongoing. We expect to provide education through these teaching conferences to 50 individuals attending sessions at PMH over the course of the year and 100 individuals at outreach sites. CME Lectures in Gaborone UPenn specialists will provide continuing education lectures for physicians, nurses, pharmacists, and other health care providers in the Gaborone area. These will occur every 3-4 months over the course of the year. We expect to provide education through these

teaching conferences to 20 or more providers attending each of these sessions.

Implementation of the National Guidelines for HIV-related Palliative Care UPenn specialists will help implement guidelines for the palliative care of PLWHA. UPenn physicians will continue to collaborate with the palliative care unit at the MOH as well as continue to participate in the roll out of the palliative care guidelines. We expect to continue to participate in implementing guidelines for palliative care throughout the year.

The UPenn program in Francistown began in November 2005. In FY07, we will continue to have 2 UPenn Specialists working in Francistown. The 2 specialists will divide their time equally between NRH and outreach. Activity 2: NRH The NRH component will be designed in collaboration with the hospital Superintendent, and will include inpatient and outpatient care, training, curriculum development and didactic teaching. FY07 outcomes at NRH include: 1) Provision of clinical, psychosocial, and social palliative care to about 600 HIV inpatients (non-TB) at NRH, 2) provision of care to 180 outpatients newly started on ARV therapy, 3) provision of outpatient care to 1,000 outpatients maintained on ARV therapy, 4) provision of indirect palliative care to approximately 1,000 HIV patients through interactions with other providers at NRH, and 5) provision of training to approximately 20 physicians, nurses, and nursing students employed by NRH who round with the UPenn specialists during the year. This teaching will be in the form of bedside teaching during daily rounds. Note that many of the patients in #3 above will also be seen by other providers over the course of a year since return visits are not directed to any one physician. Therefore, these are not unique patient visits, but are the total number of patients seen over the course of a year who are on ARV therapy. Outreach Program The goal is for 1 specialist to spend periods of 2 consecutive weeks at each of several locations including Tutume and Masunga. At outreach sites, the UPenn specialist will be involved in the following: 1) inpatient consultations, 2) outpatient consultations, 3) one-on-one mentoring, and classroom lectures, and 4) phone consultation to physicians in the area. UPenn will provide direct consultation and palliative care for approximately 200 inpatients without active TB, 70 inpatients with active TB, and 1,000 outpatients who were previously started on ARV therapy. They will provide phone consultation to advise on care of approximately 300 patients during the fiscal year. Educational Programs at NRH Penn providers will continue to direct intake rounds Monday through Friday each week, which serves as one of the main teaching conferences for the interns and medical officers. UPenn staff will continue to organize both a weekly didactic lecture series and HIV conferences for interns, medical officers, and other healthcare providers at NRH. They will provide education through these teaching conferences to 20 individuals attending sessions at NRH over the course of the year, and 40 individuals at outreach sites.

Implementation of the National Guidelines for HIV-related Palliative Care UPENN specialist will help implement guidelines for palliative care of PLWHA at NGH as described above.

07-T1203: ITECH - Human Resource Development.

This activity has USG Team Botswana Internal Reference Number T1203. This activity links to the following: T1110.

The International Training and Education Center on HIV (I-TECH ) will help recruit staff for 5 MOH laboratories in Gaborone and Francistown, as well as the IHS. There is a desperate need of laboratory technicians (lab techs) in Botswana. Currently there is a three year diploma program at the IHS that only graduates 15 lab techs every three years. An assessment of the laboratory technician program capacity at the IHS concluded that with more instructors, the IHS would be able to provide a double stream of training and double the current number of students graduating after three years. FY07 funds are requested for I-TECH to support the recruitment and hiring of five additional lab tech instructors, and 3 laboratory assistants. This financial support is likely to be expected to continue for the next few years, with future planning intended to explore development of the three-year program into a four-year Laboratory Technician Bachelor's degree at the University of Botswana (UB).

1. Institute for Health Sciences 5 Teachers for Institute of Health Sciences (US $ 120,000) Annual salary: US $ 24,000 (including benefits) Justification for position The teachers will provide lectures in the fields of microbiology, hematology, immunology, chemistry and cytology/histology. They will also be responsible for laboratory training sessions.

3 laboratory assistants for IHS (US $ 36,000) Annual salary: US $ 12,000 (including benefits) Justification for position The laboratory assistants will assist the teacher during the laboratory training sessions; they will also prepare laboratory specimens, mediums, reagents, and supplies for the training sessions.

2. Botswana-Harvard HIV Reference Laboratory 1 laboratory scientist at Botswana Harvard Partnership Laboratory Annual salary: US $ 36,000 (including benefits) Justification for position The laboratory scientist will be in charge of testing infant DBS samples and the QA system in the laboratory for infant DBS. This position will also assist the ARV treatment program by doing CD4 counts, VL, and resistance testing.

3. Jubilee Lab in Francistown 1 laboratory technician at ARV Jubilee Lab in Francistown Annual salary: US $ 24,000 (including benefits) Justification for position The laboratory technician will be in charge of the testing of infant DBS samples and the QA system at the ARV Jubilee Lab in Francistown. This position will also help the staff with different laboratory testing. 4. NQAL 1 laboratory scientist at the NQAL Annual salary: US $ 36,000 (including benefits) Justification for position The laboratory scientist will be in charge of the NQLA. This position will characterize proficiency testing specimens for different HIV laboratory testing to support the NQAS; coordinate and organize training in collaboration with the QA Unit at MOH for lab techs; and will assist laboratories in the annual proficiency testing.

1 laboratory technician at the NQAL Annual salary: US $ 24,000 (including benefits) Justification for position The laboratory technician will be responsible for daily HIV testing in the laboratory, characterization and aliquot of proficiency testing panels for HIV, hepatitis serology, rapid HIV test, and microbiology to support the NQAS in the country.

A portion of these funds will cover technical assistance and administrative costs for I-Tech in-country.

07-X1307: ITECH: Human Resource Development.

This activity has USG Team Botswana Internal Reference Number X1307. This activity links to the following: BCC activities & X1302 & X1402.

GOB seeks to build its capacity to provide strategic information on HIV prevention and care. The overall objective of these activities is to increase the M&E capacity of the HIV response at the district level, such as improving the national level coordination of reporting, strengthening and streamlining the data systems, and supporting overall efforts to improve the quality of HIV care. To meet these objectives, GOB seeks to add human resources at both the district and national level. At the district level, HIV programs are delivered through both the MLG and the MOH. At district level, NACA is represented by the DAC office.

MOH & NACA Information Management Officers: 2007 EP funds are requested for I-TECH to recruit and hire 45 Information Management Officers. Twenty-one of these positions will be at the DAC Offices working with NACA and 24 positions will be with the MOH-Informatics Unit as District Program Information Officers. I-TECH will work closely with MOH and NACA to define I-TECH's role in providing job orientation, mentoring and supervision, technical assistance and administrative support as well as developing the plan to integrate these new staff members into government service over time. The scale-up of strategic information capacity will be phased-in over a 1 year period, based on a plan that will be developed during an FY06 assessment trip. The following positions will be recruited and managed by I-TECH:

Job Title: Information Management Officers Grade: C3 45 Salary: 45 @ $11,154.00 $501,930.00 Fringe benefits: 45 @ $2,788.50 $125,482.50 Total cost: $627,412.50

MOH Technical Advisors: In addition, I-TECH will provide two long-term technical advisors to the MOH. One will be a senior strategic information/systems specialist, and the other an epidemiologist/surveillance specialist. The strategic information advisor will support the development of reporting tools and systems that are responsive to improving the quality of HIV care as well as training, mentoring and supervising of the new staff. The epidemiologist/surveillance specialist will assist with the design of disease surveillance systems in collaboration with the GOB and HHS/CDC/BOTUSA.

Job Title 1: Senior Strategic Information/Systems Specialist Job Title 2: Epidemiologist/Surveillance specialist Grade: Contractors Salary: 2 @ $50,000.00 $100,000.00 Fringe benefits: 2 @ $11,250.00 $22,500.00 Relocation and Allowances: 2 @ $42,560.67 $42,562.67 Total cost: $165,062.67

MOH & MLG - Other staff: In order to address immediate and short-term workforce requirements, I-TECH will assist GOB in recruiting, managing, and placing several key positions within government agencies. Together and individually, these positions will strengthen the ability of certain agencies within GOB to implement HIV/AIDS programs more efficiently; to develop, implement, and maintain proper standards for delivery of EP-funded services; and to determine direction and assess ultimate achievement of EP goals. These positions will be hired at the government pay scale to facilitate their smooth integration, in the long-term, into government services.

These positions include: 1) for MOH's DPPME one chief health information officer, one principal systems analyst, two IT officers, and one senior systems analyst programmer, 2) for MOH's DHAPC one data manager, two data clerks, and one public health specialist,

3) For MLG's Department of Primary Health and Primary Services one M&E health officer.

This entire staff will work towards the creation of the Health Management Information System (HMIS). The senior systems analyst programmer will spend half of his/her time helping on the integration of standalone systems in the MOH's DPHAPC. These positions are to be absorbed into the public structure, except the epidemiologist and the strategic information officers, which are contract positions and directed by the current need. Once the DHAPC personnel are trained to conduct the surveillance work and the HMIS is in place, the contractors' positions will be phased out. The pay structure will be similar to that of the GOB to facilitate the integration of the new positions in the public structure.

Job Title MOH-IPMS (X1302) Salary Fringe benefit Total cost IT Officer (data handling) 1 C2 @ $13,831 $3,457.76 $17,288.79 IT Officer (SQL Server) 1 C1 @ $17,148 $4,286.90 $21,434.48 Pr. System Analyst 1 D3 @ $24,452 $6,112.93 $30,564.66 Chief Health Information Officer 1 D1 @ $32,338 $8,084.48 $40,422.41 Senior System analyst (Application Programming) 1 D4 @ $21,265 $5,316.21 $26,581.03 5 $27,258.28 $27,258.28 $136,291.38 MOH-Surveillance (X1303) Data clerk 1 B1 @ $7,254 $1,813.45 $9,067.24 Data clerk 1 B1 @ $7,254 $1,813.45 $9,067.24 Data Manager 1 D4 @ $21,265 $5,316.21 $26,581.03 Public Health Specialist 1 D3 @ $24,452 $6,112.93 $30,564.66 4 $15,056.03 $15,056.03 $75,280.17 MLG HQ M&E UNIT Monitoring and Evaluation Officer 1 C1 @ $17,148 $4,287.00 $21,435 Data Manager 1 D4 @ $21,265 $5,316.25 $26,581 2 $38,413.00 $9,603.25 $48,016

Total cost of program 11 $80,727.31 $51,917.56 $259,587.80 I-TECH will recruit and hire all of these positions. I-TECH will facilitate the hiring process and it will manage temporarily these positions while working with GOB on the integration of these positions in the public service.

In order to support this scale up of human resources, I-TECH realizes the need for a full-time presence in Botswana. FY07 funds are requested to support a percentage of the infrastructure and staffing needs of I-TECH, including an office in Gaborone with staff for program management, administration, and technical assistance.