07-C0615: Project Concern International.

This activity has USG Team Botswana Internal Reference Number C0615. This activity links to the following: C0602 & C0613 & C0802 & C0811 & C0814 & C0816 & P0101 & P0104 & T1101 & T1107 & T1108 & T1109 & T1113 & T1114.

Activity Narrative An estimated 10,000 - 25,000 children under the age of 15 are HIV-infected. The care and treatment of infants and children with HIV/AIDS poses the following distinct challenges: 1) Pediatric ARV formulations are not readily accessible; 2) Appropriate technology for testing is limited; 3) Overall screening of infants and children is insufficient; 4) There is a lack of holistic and integrated care for children; 5) clinical expertise in pediatric HIV/AIDS is still growing; 6) Insufficient guardian care and support may be lacking in the home, so children have to rely on others to help with adherence and follow up. All of these pediatric-specific issues are made more complicated by the challenges and constraints posed by ARV distribution and adherence for adult PLWHA. These challenges are surmountable but need to be taken into account when designing and implementing an effective strategy to improve ARV therapy and palliative care for HIV- infected children in Botswana.

Building on experiences addressing the needs of children and families with HIV/AIDS in several other countries, PCI, in collaboration with the MOH and other key stakeholders, proposes to design and implement a project that will support and strengthen existing programs that address pediatric ARV therapy related issues. In response to the needs and context reflected above, this project aims to improve ARV tretament uptake and adherence in HIV infected infants and children through a program of linkages, coordination, and referral that emphasizes capacity building for civil society in pediatric ARV therapy support.

The project will 1) strengthen the capacity of caretakers and caregivers of PLWHA and OVC to support optimal care and treatment for HIV infected infants and children, 2) increase community access to available child/infant-appropriate HIV testing, 3) enhance case finding and referral to appropriate care and treatment services for children, and 4) maximize linkages among these services. Capacity-building will be conducted in collaboration with Baylor University, I-TECH, and other key resource organizations as appropriate. The activities described in this activity narrative are for a one-year period; however it is expected that year one activities will lay down a foundation for national scale-up during subsequent years.

In FY07, activities will focus on Francistown. Key elements of the program include: 1. Improving identification of HIV-infected children and linking them to care and treatment support services, through: a. Engagement of Civil Society Organizations (CSOs) (traditional authority structures, local NGOs, CBOs, FBOs, PLWHA Associations, etc.) and networks of CSOs that are involved in the care and support of infants, children, and adults living with HIV/AIDS, including OVC, HBC, and PMTCT programs. b. Establishment of new, and strengthening of existing, referral systems and linkages among key programs and health sector divisions (e.g., clinics and hospitals, PMTCT, immunization, maternal child health, OVC, home based care, inpatient and outpatient services, private health providers, school health initiatives, the Masa ARV therapy program). c. Improving data management, record keeping, and monitoring of patients once they are captured in the system by using appropriate paper-based and electronic formats to enhance existing MOH (responsible for hospitals) and MLG (responsible for clinics) systems.

PCI will complete the following steps in order to determine details of project design and implementation, including the final selection of project sites, partners and indicators, and the establishment of targets and deliverables. Throughout this process of planning and

implementation, PCI will foster the engagement and support of key stakeholders, as well as continuous quality improvement through performance monitoring, reflection and learning.

1. A rapid assessment and mapping process will be carried out to determine specific needs and opportunities, challenges and resources that will need to be taken into consideration during design and implementation of the project. A detailed workplan will then be developed in close coordination with the EP USG Team, collaborating partners, and other relevant stakeholders. Promising practices and lessons learned in Botswana will be reviewed and incorporated. 2. Assessments of organizational and technical/programmatic strengths and needs will be conducted with partner CSOs and relevant health care workers. Training strategies and modules to address needs identified through these assessments will be developed and/or adapted. Training activities will be implemented in coordination with ongoing and existing training for ARV therapy delivery and adherence, OVC, PMTCT or other related subjects and areas of programming. 3. CSOs and relevant health care workers will be supported to incorporate pediatric ARV therapy adherence counseling into their routine outreach and selected CSOs will be provided with mini-grants to support their pediatric ARV therapy specific activities. Development of a nutrition-for-ARV therapy training module designed for pediatric application based on PCI experience to date in Zambia and available experience within Botswana and the southern African region. Recommendations for further research in action on this topic will be made

In Botswana, over 14,000 (UNAIDS 2006) children under the age of 15 are HIV positive, but relatively few have access to adequate care, support and treatment services. Challenges to the care and treatment of infants and children with HIV/AIDS include: not readily accessible pediatric ARV formulations; limited testing technology; insufficient screening of infants and children; lack of holistic, integrated care for children; limited clinical expertise in pediatric HIV&AIDS; and insufficient guardian care and support in the home. These are further complicated and challenged by the constraints that also exist with adult ART distribution and adherence.

PCI and key technical partner BroadReach Healthcare will design and implement a project that will support and strengthen existing programs that address pediatric ART-related issues, in collaboration with the MOH and other key stakeholders. This project will improve ART uptake and adherence in HIV positive infants and children through a program of linkages, coordination and referral built upon a foundation of capacity building for clinicians and civil society regarding pediatric ART delivery and support. The project will enhance care and treatment for HIV positive infants/children; engage caretakers and caregivers of PLHA and OVC with the knowledge and skills necessary to support optimal treatment for HIV-positive infants and children; increase the availability of child/infant-appropriate HIV testing; enhance case finding and referral to appropriate care and treatment services for children; and maximize PMTCT interventions. This initiative will provide a useful framework for replication throughout Botswana. Key elements include: 1. Coordination and collaboration with key resource groups. 2. Improving screening and identification of HIV infected children through: a. Engagement of CSOs (traditional authority structures, local NGOs, FBOs, PLHA associations, etc.) and networks of CSOs that provide care and support to infants and children, including OVC and PMTCT programs. b. Establishment of effective referral systems and linkages with and between key programs, health sector divisions (e.g., Clinics and Hospitals, PMTCT, Immunization, Maternal Child Health, OVC, Inpatient and Outpatient Services, Private health providers, School Health Initiatives and the Masa ART program) and resources and participation in advocacy efforts designed to increase the profile and attention paid to pediatric ART issues. c. Improving data management, record keeping and monitoring of patients once captured in the system by using appropriate paper-based and electronic formats to enhance existing MOH (responsible for hospitals) and Ministry of Local Government (responsible for clinics) systems. 3. Improving diagnostic capacity and capabilities by supporting the decentralization of infant PCR as well as CD4 technology and innovative techniques such as dried blood spot to allow for more rapid and efficient screening, identification and staging of children. 4. Building the capacity of proxy care givers (e.g., grandmothers, CSOs, community/home based care or OVC outreach workers) by providing training on pediatric ART issues and concerns, including ART adherence, adapting existing training courses. In collaboration with its technical partners, PCI will develop a comprehensive approach to training and supportive supervision for pediatric HIV/AIDS care and treatment at the community level, focusing on building the capacity of families/caregivers to recognize problems, provide proper treatment in the home, and know when to refer children to the clinic. Technical assistance in pediatric HIV monitoring and evaluation will be provided to CSOs and ongoing support for needs-based continuing education and technical updates will be included. 5. Exploration, with the MOH and leading medical and nursing training programs, of ways of incorporating pediatric ART issues into ongoing pre-service curricula so that medical and nursing students coming out of their preparatory or residency phases of education are better prepared to address this critical health care need. 6. Working with the Drug Regulatory Unit (DRU) to proactively accelerate streamline processes such as registration of new pediatric formulations and fostering collaboration with selected pharmaceutical companies working on making ART and related procedures and processes as infant/child-friendly as possible. 7. Utilization of a "positive deviance" approach to identify children who are doing well on ART, and/or ART sites which do particularly well with children; learn from that positive experience; and bring that learning to scale through the incorporation of lessons into behavior change communication, counseling, outreach and support strategies and materials.

Through a process of planning and implementation, PCI will foster the engagement and support of key stakeholders, as well as continuous quality improvement through performance monitoring, reflection and learning. PCI will complete the following steps: 1. A detailed assessment and mapping process will be carried out to determine specific needs and opportunities, challenges and resources that will need to be taken into consideration during design and implementation of the project. In close coordination with the USG PEPFAR team, pediatric ART focus sites and target areas will be determined. 2. Assessments of organizational and technical/programmatic strengths and needs will be conducted with partner CSOs and target clinicians. Training strategies and modules will be developed and/or adapted and provided to target clinicians and CSO outreach workers on pediatric ART and adherence-related issues. Training will be topic specific and in-depth, but integrated into ongoing and existing training for ART delivery and adherence, OVC, PPTCT or other related subjects and areas of programming. 3. CSOs and clinicians will be supported to incorporate pediatric ART-adherence counseling into their routine outreach or clinical service delivery work, and selected CSOs will be provided with mini-grants to support their pediatric ART specific activities. 4. PCI will develop a nutrition-for-ART training module designed for pediatric application based on its experience in Zambia and other available information. 5. PCI, in collaboration with its partners and the MOH, will conduct national advocacy workshops on pediatric HIV/AIDS care and treatment designed to share lessons learned, best/promising practices and tools/resources available. Facilitation of collaborative planning for bringing quality pediatric ART services to scale will be provided by PCI.

Partnership PCI will work in close coordination with key technical partner, BroadReach Healthcare. BroadReach brings a wealth of experience and technical expertise in the area of HIV/AIDS, particularly with ART program development, implementation, and management in different countries. In Botswana, BroadReach was directly responsible for developing and managing the Masa Program. BroadReach is known for successfully applying innovative private sector approaches to public sector challenges. Committed to the community-based model of care, BroadReach works closely with local community-based community support organizations (including local churches, home based care programs, PLWHA support groups, and small businesses) to ensure the community itself is supporting those on treatment through treatment literacy and education sessions, adherence support, home-based visits, patient uptake programs, and support group counseling sessions. During the assessment and project design phase, the complementary roles of PCI and BroadReach and their respective geographic coverage will be further defined.