07-C0620: Harvard.

This activity links with T1111 & T1112.

This is a continuing program of the BHP to support and strengthen the Masa ARV therapy program through the following 4 activities:

ACTIVITY 1: The CMT was designed to provide sustainable training capacity for integrated, high-quality HIV/AIDS treatment at public sector ARV sites in Botswana. It consists of on-site and centralized training and support activities, focusing on the development and training of site-level Master Trainers who in turn provide training to health professionals at their respective sites. By end of FY06, CMT will have assessed 16 sites, initially supported and followed up with 10 sites, assessed and supported/upgraded 10 clinics to prescription and dispensing level, and trained 1200 health workers to deliver ARV services.

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

In FY07, the remaining ARV sites will receive the full package of training and support , including needs assessments, on-site practical support, centralized classroom and attachment training at site IDCCs, immediate on-site support, and quarterly follow-up visits. A total of 32 core team site-level Master Trainers will be trained and will supervise care and treatment at their sites.

BHP will expand its clinical support to ARV sites in FY07 through these activities: 1. Strategies to improve, integrate, monitor and evaluate services and programs at ARV sites, and to increase capacity through improved integration of programs. This includes training of the CMT's on Quality Assurance and Improvement and implementation of QA activities in collaboration with I-TECH at the ARV site level;

2. Telephone Site Support for HIV/AIDS Management to enable clinical and pharmacy staff at all 32 ARV sites to obtain advice on difficult cases, etc. from core Master Trainers and other BHP staff by toll free phone to ensure the best, quickest, and most efficient care and treatment possible;

3. In collaboration with Masa, training of clinical core teams to train the nursing cadre at their sites to start prescribing and dispensing for non-complicated first line therapy;

4. Development of educational tools for ARV sites, including a clinic reference manual and CD ROMs;

5. Provision of training by Pharmacy Master Trainers (PMT) on Supply Chain Management, Rational Drug Use, logistics, dispensing techniques, and monitoring of toxicities for all 32 sites, and provide on-site support to 20 ARV dispensing units. The PMT will also collaborate with Central Medical Stores on 1) forecasting, 2) quantification, 3) ordering and delivery of ARV drugs to the newly dispensing satellite clinics, 4) monitoring and evaluation, 5) developing/updating existing training manuals, and6) increasing the pediatric effort by bridging efforts on testing and diagnosis of children under 5 years.

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

insufficiency, and delays in equipment delivery. A total of 25 laboratory technicians were trained on CD4 systems and 6 have been trained on VL to date. In FY06, decentralization, set up, and training support for VL testing will resume and be completed.

In FY07, the LMT/Site Support Program will continue to support the established CD4, VL decentralized and expanded labs from FY06 and add hematology, chemistry, and microbiology re-training and support. By the end of FY07, all laboratory technicians from the 12 decentralized laboratories will have been fully trained in CD4 and VL, re-trained in hematology, chemistry, and microbiology, and all 12 labs should be fully functional. Attachment training at the Botswana-Harvard HIV Reference Lab, site support, telephone site support, and capacity building through development of site-level laboratory master trainers will continue. An estimated 30 technicians, 6 from private sector, will be trained. The LMT, in collaboration with MOH and HHS/CDC/BOTUSA, will formalize the training manuals on CD4, VL, hematology, chemistry and microbiology, including TB, and the LMT will train on the expanded manual during all training efforts listed above. Additionally they will provide training on lab data management, reagent logistics, and quality assurance in FY07.

ACTIVITY 3: Establishment of an M&E Unit within the Masa Program to develop standardized paper-based and electronic monitoring systems to track ARV patients, specifically, clinical, laboratory and pharmaceutical monitoring systems. This will include development of indicators and data capture instruments, harmonization of indicators, development of data flow mechanisms including reporting guidelines and instruments, reporting schedules, and routine feedback documents to the sites.

Recently, a data server was purchased and installed within the MOH. Ten data entry clerks were hired in April 2006 and are presently deployed at ART sites to enter manual data from files into the electronic system, and update the ARV data at all 32 sites. A data manager understudy was hired. Staff at the ARV treatment sites will be trained on the new data capture instruments, indicators, quality and flow. A consultant will be brought in to assist in setting up the data warehouse, and working on integration and security issues.

In FY07, activities will continue in line with the MOH vision of developing a viable and sustainable monitoring system for the ARV program. The existing Masa application will be evaluated and updated to serve the increasing numbers of patients who will come into the system. Additional software required for front-end users of the server will be purchased. Relevant staff at ARV treatment sites will be provided with refresher training on data aspects and M&E. Site visits will be continued to monitor data quality and data activities at the sites.

07-T1112: Harvard (field).

This activity has USG Team Botswana Internal Reference Number T1112. This activity links to the following: C0609 & C0613 & C0620 & T1003 & T1004 & T1005 & T1101 & T1103 & T1111 & T1201 & T1202 & X1302 & X1305 & X1306.

This is a continuing program through the Botswana-Harvard School of Public Health AIDS Initiative Partnership (BHP) to support and strengthen the Masa ARV therapy program through the following 4 activities:

ACTIVITY 1: Clinical Master Trainer/ARV Site Support (CMT) was designed to provide a sustainable training capacity for integrated, high-quality HIV/AIDS treatment at public sector ARV sites in Botswana. It consists of on-site and centralized training and support activities, focusing on the development and training of site-level Master Trainers who in turn will provide training to health professionals at their respective sites. By end of FY06, CMT will have assessed 16 sites, initially supported and followed up with 10 sites, assessed and supported/upgraded 10 clinics to prescription and dispensing level, and trained 1200 health workers to deliver ARV services.

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

In FY07, the remaining ARV sites will receive the full package of training and support. This includes 1) a needs assessment, 2) on-site practical support, 3) centralized classroom and attachment training at site IDCC, 4) immediate on-site support, and 5) quarterly follow-up visits. A total of 32 core team site-level Master Trainers will be trained and will supervise care and treatment at their sites.

Harvard will expand its clinical support to ARV sites in FY07 through these activities: 1. Development and implementation of strategies to improve, integrate, monitor and evaluate services and programs at ARV sites, and to increase capacity through improved integration of programs. This includes training of the CMT's on QAI and implementation of QA activities in collaboration with I-TECH at the ARV site level;

2. Telephone Site Support for HIV/AIDS Management to enable clinical and pharmacy staff at all 32 ARV sites to obtain advice on difficult cases, etc. from core Master Trainers and other BHP staff by toll free phone to ensure the best, quickest, and most efficient care and treatment possible;

3. Training of nurses in collaboration with MASA, clinical core teams to train the nursing cadre at their sites to start prescribing and dispensing for non-complicated first line therapy;

4. Development of educational tools for ARV sites, including a clinic reference manual and CD ROMs;

5. Provision, in addition to activities 1-4, by the Pharmacy Master Trainers (PMT) of training on Supply Chain Management, Rational Drug Use, logistics, dispensing techniques, and monitoring of toxicities for all 32 sites, and provide on-site support to 20 ARV dispensing units. The PMT will also collaborate with Central Medical Stores on forecasting, quantification, ordering and delivery of ARV drugs to the newly dispensing satellite clinics, monitoring and evaluation and developing/updating existing training manuals; and 6)

increasing the pediatric effort by bridging efforts on testing and diagnosis of children under 5 years.

ACTIVITY 2: The Laboratory Master Trainer (LMT) has been instrumental in the decentralization of CD4 and viral load (VL) testing (infrastructure funded by ACHAP and BOTUSA). CD4 services were decentralized to 12 laboratories in FY06. Unfortunately, VL testing was delayed due to machinery incompatibility, electrical power insufficiency, and delays in equipment delivery. A total of 25 laboratory technicians were trained on CD4 systems and 6 on VL to date. Decentralization, set up, and training support for VL testing will resume during the remainder of FY06.

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

ACTIVITY 3: Establishment of a Monitoring and Evaluation (M&E) Unit within the National ARV (MASA) Program to develop standardized paper-based and electronic monitoring systems to track ARV patients, including clinical, laboratory, and pharmaceutical monitoring systems. This will include development of indicators and data capture instruments, harmonization of indicators, development of data flow mechanisms including reporting guidelines and instruments, reporting schedules, and routine feedback documents to the sites.

Recently, a data server was purchased and installed within the MOH. Ten data entry clerks were hired in April 2006 and are presently deployed at ART sites to enter manual data from files into the electronic system, and update the ARV data at all 32 sites. A data manager understudy has been hired. Staff at the ART sites will be trained on the new data capture instruments, indicators, quality and flow. A consultant will be brought in to assist in setting up the data warehouse, and working on integration and security issues.

Activities for FY07 will continue in line with the MOH vision of developing a viable and sustainable monitoring system for the ARV program. The existing Masa application will be evaluated and updated to serve the increasing numbers of patients who will come into the system. Additional software required for front-end users of the server will be purchased. Relevant staff at ART sites will be provided with refresher training on data management issues and monitoring and evaluation. Site visits will be continued to monitor data quality and data activities at the sites.