08.P0114

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. In 2007 MOH PMTCT Unit was able to hire a Data Manager and the PMTCT Unit was

supported in terms of data quality management. In January 2008, the Data Manager had resigned, leaving

the Unit again without support for activities around implementing, piloting, roll out trainings. 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 activities to

support the PMTCT strategy are:

1. Human capacity development for the PMTCT Unit: Hire and second to MOH/PMTCT a data manager:

Grade: D2 @$40,500 per annum = $54,000 (including salary, benefits, etc)

Justification for the Position

This position will supervise two data clerks and be responsible for the PMTCT information systems, M&E.

The position is stationed in Gaborone at MOH.

2. I-TECH Training Coordinator - $54,000 per annum @ 10% time

Justification for the Position

This position will contribute to the overall efficacy of the training portions of this project

In collaboration with the entire PMTCT team, I-TECH will provide ongoing mentoring and team building

among the national PMTCT 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. Train 16 PMTCT Unit MOH staff in SPSS. ($50,000)

2. PMTCT data quality: Complete, accurate, and timely data are critical in M&E the PMTCT program. I-

TECH will pilot the PMTCT data collection forms in 4 districts with MOH guidance, and based on the

findings revise the tools. I-TECH will roll out the tool in all 24 districts; train health care workers (including

PMTCT District Coordinators) in all the districts on the new tool; Develop and Conduct a data audit,

immediately following the introduction of the new system; Create and maintain a system for regular audits of

data; ($240,500)

3. EID (Early Infant Diagnosis): Starting November 2007, I-TECH is assisting the MH/PMTCT Unit with data

collection for the EIS program- this activity needs to continue as at this point in time, MOH is not ready

given the shortage of human resources to take on this activity. ($50,000)

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

08.C0610: I-TECH - STI Syndromic Management

Between 2004-2007, the International Training and Education Center on HIV (I-TECH) successfully

supported the MOH National STI Training and Research Center (NSTRC) to implement the revised

Sexually Transmitted Infections (STI) syndromic management training, including the introduction of

acyclovir for genital ulcer disease, to all districts nationwide. Training in syndromic management of STIs

includes routine HIV testing (RHT) of clients as well as risk reduction counseling. In 2007, I-TECH began

supporting the NSTRC to implement clinical mentoring among their district trainers and health care

providers.

In 2008, I-TECH will continue to support the NSTRC to scale up clinical mentoring to the remaining districts

through training of clinical mentors and providing support to trainers during the initiation of clinical

mentoring. PEPFAR funds will be used to develop and reproduce a clinical mentoring guide (training

materials) for all district trainers (27 trainers including master trainers), as well as support partial time and

travel of the I-TECH Quality Improvement (QI) Specialist who is developing this training and supporting the

NSTRC with the scale out.

I-TECH will assist the NSTRC to strengthen the Supportive Supervision Visits conducted. In 2007, there

were 3-4 supervisory visits in 14 districts conducted by the district trainers who were trained by Master

Trainers. The plan is to conduct supervisory visits into the remaining districts (10) and maintain the quality

of mentoring and training in the initial 14 districts.

2008 funds will support four staff at the NSTRC until such time as the MOH is able to absorb these positions

and hire them directly. These include:

- STI Master Trainer at D4 level

- STI Training Coordinator at D3 level

- STI Master Trainer/M&E Officer, all continuing from prior years and

- STI Data Clerk, part time to be supported with 2008 funds.

2008 funds are also requested for MOH/NSTRC staff development, specifically funding the study tour costs

for the MOH/STI Training Coordinator and two other STI Master Trainers from implementing districts to

attend the University of Washington's Principles of HIV & STD Research Course in July 2008.

The I-TECH funded STI Master Trainers are responsible for supporting the district trainers with their

supportive supervision visits, responding to efforts to improve the quality of care, and reporting on the visits.

One of these Master Trainers will also be responsible for scaling up use of acyclovir to the remaining

districts (ten additional districts in Phase 3), providing support to the trainers and pharmacy technicians in

the scale up, and monitoring the correct prescription and stock levels at district clinics and hospitals.

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 I-TECH funded Master Trainers will work with the

NSTRC coordinator and clinic staff, administration, Central Medical Stores (CMS), and other stakeholders

to improve the quality of STI care.

2008 funds are requested to support half the salary and relocation costs of a M&E Technical Lead to be

based in the Gaborone office, as well as partial time and one trip for I-TECH (Seattle-based) QI Specialist to

work with the I-TECH M&E Lead to build the capacity of the MOH/STI program with in-service training, how

to enter, analyze and interpret data to result in evidence-based planning activities. I-TECH will conduct

individual training assessments of the STI unit staff in order to tailor training based on individual need and

conduct this training accordingly.

Additional printing of the STI syndromic management training materials (1,000 Participant Handbooks) will

be needed to provide for two additional years' worth of training.

08.C0609: University of Pennsylvania - Palliative Care Services Support

The scope and direction of the Penn - Botswana program continues to evolve. At the inception of the

PEPFAR funded program, Penn deployed one Botswana based faculty member in Gaborone with the goal

of providing high quality HIV related palliative care and treatment training to clinicians at PMH and NRH.

The program has expanded to include an outreach program to each district hospital where the goals are to

increase knowledge and improvement in the standard of patient care to those suffering with HIV/AIDS and

opportunistic infections. In 2007 with 6 specialists deployed at both referral hospitals the program will

directly influence the treatment of some 5,000 inpatients at the two referral hospitals and have an indirect

influenced on the care and treatment of some 6,000 patients at the district hospitals by having delivered

some 80 training sessions to 60 doctors under our outreach education program.

During 2007 Penn specialists have also assisted the MOH in developing their guidelines for palliative care

and will, by the end of COP07, have developed with I-TECH the clinical guidelines covering palliative care

for the MOH. In 2008 a curriculum will be compiled for the training and the service will be extended to some

periferal primary hospitals.

In patient services

Penn will have a total staff presence of four internal medicine specialists in Gaborone and two in

Francistown. They will provide inpatient care to the medical department that has a total of some 150 beds

within the two referral hospitals. However with the severe overcrowding of these beds it is expected that

these staff will deliver direct care to some 5000 inpatients suffering with HIV/AIDS and its co -infections.

As well as providing direct inpatient care Penn will also undertake a structured educational training program

aimed directly at affecting the care practices other internal medicine clinicians perform as well as a similar

program given to all clinical staff (doctors and some nursing staff) in the practice of medicine related to

HIV/AIDS. Some 250 clinicians at the 2 referral hospitals will be able to benefit from this education program.

Out patient services

During 2007 Penn started specialized HIV clinics at both referral hospitals. These clinics created a "one

stop shop" idea for patients with HIV and complications such as metabolic problems, co-morbidity issues

and co-infections that can be managed as outpatients. Clinics are run three days a week and during COP08

it is expected that some 2,500 to 3,000 patients will be managed in these specialized clinics.

Outreach services.

Botswana's 2 referral hospitals have patients referred to them by 11 district hospitals and 14 primary

hospitals. With the current HIV/AIDS pandemic, the increasing rate of OIs in patients suffering from

HIV/AIDS, the lack of clinical skills in the primary and district hospitals to manage these opportunistic

infections leads to their subsequent referral to the two referral hospitals. This is in itself is a major cause of

their overcrowding. The Penn outreach program aims at training with both lectures and direct bedside

teaching the management of patients with HIV/AIDS and opportunistic infections.

It is expected therefore that some 180 lectures will be delivered to some 60-70 primary and district hospital

doctors. This will directly affect the care of some 8,000 patients admitted to these primary and district

hospitals with HIV/AIDS and hopefully stop up to 2500 being referred to district and eventually to the main

referral hospitals in FY2008.

08.C0603: I-TECH/Uppen- Improved PAP Smear Testing

Cervical cancer is a relatively rare disease in the developed world due to organized screening and

appropriate treatment of pre-cervical cancer lesions, awareness amongst the general public and healthcare

workers, strong advocacy from civil society, as well as prioritization of women's health issues in these

countries. Women in poorer countries face problems of limited access to care, highlighting the inequity

inherent in this disease.

There are close to 500 000 new cases of, and 275 000 deaths from cervical cancer world wide, with 80% of

these occurring in resource-limited settings. Twenty percent of all annual global deaths from cervical cancer

occur in Sub-Saharan Africa. Cervical cancer accounts for > 25% of all cancers in Botswana, and it is the

leading cancer killer in women. Of those presenting with cervical cancer in Botswana, 90% of them have

never been screened.

Persistent infection with oncogenic types of HPV is essential for development of invasive cervical cancer.

Risk factors for persistence occur more frequently in resource-limited countries like Botswana.

HIV infected women are thought to be at highest risk for cervical cancer. This is thought to be due in part to

the higher prevalence of HPV high risk subtypes, more rapid carcinogenesis and poor immune response.

Sub-Saharan Africa is the epicentre of the world AIDS epidemic, contributing 35% of all people with AIDS,

32% of all new infections and 32% of all deaths. Out of a population of 1.7 million in Botswana, there is an

estimated 270 000 people living with HIV. Prevalence rates for HIV in Botswana are currently ~ 28% in

women in the 15-49 age group, by extrapolation, a large proportion of Batswana women can therefore be

assumed to be at increased risk of pre-cervical cancer lesions and possible invasive cervical cancer, thus

making this a new public health crisis next to TB, in Botswana.

Of the 270 000 people living with HIV in Botswana around 110 000 qualify for ARV right now. The

Government of Botswana has spearheaded the fight against HIV/AIDS, by developing the first national anti

retroviral therapy (ART) programme in Africa, launched in January 2002. To date around 85% of those

requiring treatment are receiving it.

Immune reconstitution associated with potent anti-retrovirals does not seem to be a factor in regression of

pre-cancer lesions. If indeed that is the case, then, extensive availability of ART in Botswana with

associated improved life-span, is likely to paradoxically permit progression to cancer in more women.

Taking all these factors into consideration, it is becoming clear that cervical cancer is rapidly becoming a

secondary epidemic in the wake of HIV in Botswana.

When Botswana gained independence from Britain in 1966, the country was rated as one of the 25 poorest

in the world. Just over 3 decades later Botswana status changed, and the country is now classified as a

middle income economy. This has been due to a combination of prudent use of diamond derived wealth,

sound democratic processes as well as proper governance structures which resulted in rapid economic

growth.

However, the impressive gains made in Botswana's human development have been seriously threatened by

the HIV/AIDS pandemic, and this is evidenced by notable deterioration of major social indicators such as

child and maternal mortality rates. Hence the decision to implement a national ART program, but that has

meant that most of the development resources were diverted.

Elevation of Botswana to a middle income status coincided with this decision, and this signaled to the

traditional donors to either scale down or pull out their resources dealing, a double blow to a nation already

reeling from unprecedented loss of productivity and skilled human resources, especially in the 24-49 age

group.

The government of Botswana recognizes the magnitude of the cervical cancer problem. The national

cervical cancer prevention program currently is cytology based following recommendation by the World

Health Organisation (WHO). Women with abnormal Pap smears are referred for colposcopy and biopsy,

and treatment of pre-invasive disease is through cold knife cone biopsy (and soon to include loop

electrosurgical excision procedure -LEEP) at the 2 referral hospitals (Nyangabwe Referral Hospital- NRH in

the north, and Princess Marina Hosital- PMH in the south). Those with early invasive disease have access

to hysterectomy. More advanced invasive disease is either treated for cure by radiation (external beam and

brachytherapy) and chemotherapy, and for palliation with radiation. However, with most of the health

dollars committed to the fight against HIV, Botswana had to look at her development partners for assistance

to scale up the cervical cancer prevention program, especially with regards to HIV infected women.

The ‘See and Treat' (SAT) method using cryotherapy has not been included as part of the national cervical

cancer prevention program for various reasons. However, current evidence has shown that ‘See and Treat'

can be a valuable strategy in resource limited countries such as Botswana. As no work regarding ‘See and

Treat' with cryotherapy has ever been done in Botswana, we are proposing to have a pilot program to test

the suitability and acceptability of this technique in HIV infected women attending a local clinic in Gaborone.

If the technique can be shown to be acceptable in Botswana, the results will be shared with government and

the method could be advocated for inclusion in the national cervical cancer prevention program, specifically

targeting women in rural areas where follow up would be difficult.

Lessons learned in Zambia from their SAT cervical cancer prevention program, indicate that a minimum of

40% of HIV infected women would not be suitable for cryotherapy and therefore need alternative treatment

with LEEP. As part of the program, a Gynecologic Cancer Prevention Unit (GCPU) will be set up at PMH in

Gaborone. As well as clinical care, the unit will also provide overall coordination and supervision of the pilot

‘see and treat' clinic.

Both the SAT and GCPU clinics will incorporate sexually transmitted infection (STI) care for women as part

of a comprehensive cervical care. This will be in keeping with the ethos embodied in prevention with

positives.

Activity Narrative: The initial phase of this pilot will require training of staff in visual inspection and cryotherapy, as well as

LEEP.

The SAT clinic will be located at one of the local primary clinics within Gaborone. This will be one of the

sites where HIV infected women are assessed for eligibility for ART, but with no access to cytology based

screening (not all the primary care clinics in Gaborone provide routine cervical cancer screening for

women). The GCPU clinic will be situated within PMH for proximity to other services such as access to

higher care (general anesthesia and surgery) should complications such as hemorrhage arise.

The procedure to be followed at each clinic will be detailed in the standard operating procedures to be

developed. Women presenting to the ‘see and treat' clinic will be counseled regarding cervical cancer

prevention and the procedure of speculum examination and visual inspection with acetic acid, and consent

obtained for cryotherapy should it be required. During speculum inspection, women will also be assessed

for STI and appropriate treatment guidelines followed should there be evidence of cervical or vaginal

infection. Aceto-white lesions will be recorded, followed by digital cervicography for objective record

keeping, distance consultation as well as part of monitoring and evaluation. All aceto-white lesions will be

assessed using cryotherapy eligibility guidelines for cryotherapy treatment suitability. Those meeting the

criteria for treatment will be offered same day treatment.

Women with lesions not suitable for cryotherapy, or requiring further assessment, will be referred to the

GCPU clinic where they will get a full gynecological assessment, including colposcopy, biopsy and LEEP.

STI assessment will also be part of the assessment. Those with invasive disease will be referred to the

hospital's gynecology services for further management (surgery radiation and chemotherapy), as has been

happening routinely.

PEPFAR will be supporting the following for the setting up of the SAT program:

Training:

Staff for the See and treat and LEEP clinic will need to be trained in visual inspection with acetic acid,

cryotherapy, cervicography and LEEP. Training will also be provided for diagnosis and treatment of STIs.

Supplies:

This will include equipment, both heavy (eg cryotherapy machine, LEEP generator and loops, nitrous oxide

gas cylinders, laptop computers etc) and light, stationery, printing, photocopying, telephones, bedding and

consumables.

Travel

08.C0703 University of Pennsylvania

The Penn HIV/TB program was initiated in April 2006 at PMH with PEPFAR funding, with the goals of

strengthening the care of HIV/TB co-infected persons in Botswana through training and education, clinical

consultation and collaboration with the BNTP. More than one third of all TB patients in Gaborone are

diagnosed at PMH.

It is estimated that a quarter of the 2,000 children admitted each year to NRH in Francistown are co-infected

with HIV/TB. NRH has a critical shortage of pediatric specialists: only 6 of the 10 pediatric specialist posts at

NRH are currently filled. This number includes 2 rotating pediatricians from the Baylor Center of Excellence

and an expatriate pediatrician who will be leaving Botswana in late 2007. Each year NRH pediatricians

attend to 2,000 in-patients, 2,000 HIV-infected children in the outpatient HIV clinic and provide limited

outreach work to 4 district hospitals and 12 primary care hospitals.

PMH admits more than 2,000 children per year, 10-20% of whom are co-infected with HIV/TB. There are

only 4 pediatric specialists, including 2 Baylor pediatricians. PMH is the pediatric referral center for 5 district

hospitals and pediatric specialist outreach by the Baylor Pediatric Team reaches 4 of these hospitals. This

proposal will provide pediatric specialist outreach to the fifth, Ramotswa Hospital.

2007 Achievements

In FY2007, the Penn TB/HIV program implemented changes within the reporting systems at PMH to ensure

collection of relevant information, improved TB-HIV surveillance within the facility, improved transition to

district directly observed treatment strategy (DOTS) and eventual referral for ART. During this period, the

PMH IDCC provided care to 266 HIV-TB patients, including 20 with multidrug-resistant TB (MDR-TB).

During the same period, 27 HIV-TB patients were initiated on ART, while 67 TB patients were diagnosed in

other wards and departments at PMH and referred for ART at the IDCC.

The Penn TB/HIV program conducts clinical didactic teaching and clinical mentoring at four district hospital

sites in the greater Gaborone area. The program trained 190 health care workers in TB-HIV palliative care

issues, and participated at BNTP training workshops held in Gaborone for 60 medical officers working in all

hospital facilities in Botswana (three 2-day workshops held in Gaborone, including one exclusively for

private practitioners).

Penn is collaborating with I-TECH to develop new national TB/HIV training curricula for medical officers and

nurses. Penn is actively collaborating with the BNTP to develop and implement a national strategy for MDR-

TB management, and contributed to the finalization of the national TB management manual which was

finalized with FY2007 support.

2008 Plans

PMH, Gaborone

It is proposed to continue with the 2007 activities of providing treatment, consultative and educational

services for HIV/TB co-infected patients, training of 180 health care workers in collaboration with the BNTP

and I-TECH according to the new TB/HIV curricula for nurses and medical officers to ensure adherence to

BNTP guidelines, and strengthening linkages between the hospital and the national TB and ART programs.

It is proposed to continue with the subspecialty HIV/TB clinic at PMH and to provide TB treatment to 180

HIV-infected clients with TB disease (particularly those patients with drug-resistant TB), HIV counseling and

testing to 600 registered TB patients, and clinical prophylaxis for TB to 200 HIV-infected individuals. The

Penn TB/HIV program intends to refer 600 patients for DOTS in the Gaborone City Health Clinics, and to

refer 90 TB patients for HIV care at local IDCCs.

The baseline proportion of HIV-infected IDCC clients screened for TB infection in 2007 will be evaluated

and it is intended to improve the proportion by 5%-10% in 2008. It was determined that approximately 90%

of TB patients are offered screening for HIV. The targeted rate for 2008 will increase this by 5%. In 2007,

only 50% of HIV/TB co-infected patients at PMH had baseline CD4 testing. It is intended to improve the rate

by 10%-20% in 2008.

It is proposed to increase the TB/HIV program by adding one full-time specialist and one nurse to do TB/HIV

co-infection work at PMH at a cost of $110,000. Specific areas that require more staffing include: clinical

work; infection control at PMH; outreach to the City Council Clinics and Primary Hospitals; greater

involvement in developing and implementing a nationwide TB training program; expanded participation on

ministry related committees, task forces and workshops.

It is proposed to form 2 TB Support Teams (TB teams) of lay persons trained to carry out basic diagnostic

and reporting functions for the enhanced management and diagnosis of TB and TB-HIV. Health care

workers (HCWs) are overburdened, in short supply and are currently responsible for most activities related

to TB control in the health facility. Therefore, trained local technical staff could help TB diagnosis and follow-

up. The hospital-based TB team would be comprised of two individuals (with nurse and physician backup)

who will 1) conduct simple symptom screens on all admitted medical patients to identify TB suspects; 2)

collect sputum specimens from all identified TB suspects (expectorated or induced samples); 3) transport,

retrieve and report on all specimen results to the appropriate health care teams caring for the individual

patients; 4) perform rapid bed-side HIV testing on all TB-suspects with no known HIV result; 5) submit

serum for CD4 T-cell testing on HIV infected patients; 6) initiate access to HIV and TB services for identified

patients.

A second TB support team will be based in the City Clinics and will have a similar composition with the

primary responsibility of ensuring specimen collection and reporting of all TB patients during TB treatment

(at 2 months to initiate consolidation of TB therapy in those responding to treatment and at 6 months to test

for cure). All Gaborone City Clinics will be monitored with the goal of scheduling follow up visits at the

various clinics on different days of the month such that the TB team can see all the patients. The cost for

the TB support teams will be $80,000.

Activity Narrative:

Nyangabgwe Referral Hospital, Francistown

PEPFAR funds will be used to recruit two pediatric clinical specialists to advance treatment, consultative,

outreach and educational services for HIV/TB co-infected children in Francistown. Activities include

increasing the capacity to deliver care to HIV/TB infected children in both the in- and out-patient settings at

Francistown with outreach services to all the city clinics. PEPFAR will train 15 medical officers in the

Francistown area in the care of children with TB and HIV/TB co-infection through case-based discussions

and didactic lectures. Two nurses and two social workers will be recruited to initiate a pilot contact tracing

program at PMH, focusing on 2 key areas: (1) children admitted to PMH with TB, and (2) HIV-TB co-

infected adults at the Penn-Botswana IDCC clinic who have children. USG funds will support the training of

30 medical officers and pediatricians at PMH, Ramotswa Hospital, NRH, Maun and Kasane Hospitals on

contact tracing of patients with TB and HIV/TB co-infection.

At PMH, a cough team composed of one nurse and one nursing assistant will be formed to collect samples

from children (gastric washing or induced sputa), take samples to the laboratory, and follow up on all results

via a detailed log book. This pilot project to enhance the diagnosis of TB in children has the potential for

expansion to other district hospitals. To coordinate data entry, it is proposed to recruit one data manager.

The Botswana-Penn Adult HIV/TB program began at PMH in April 2006 with FY06 support. The program

has subsequently expanded and continues to build local infrastructure to improve the care of HIV/TB

infected adults. USG funds will support the Penn-Botswana Program and their pediatric partner, The

Children's Hospital of Philadelphia (CHOP) in strengthening the pediatric partnership between PMH, NRH

and Penn-CHOP.

08.C0714

Based on the Botswana National TB guidelines and program manual, I-TECH Botswana developed a

training package for Medical and Nursing Officers. The curricula include content on TB diagnosis, TB

prevention and infection control, contact tracing, complexities of clinical management, Anti Tuberculosis

Treatment (ATT); Treatment of the dually infected patient; drug-drug interactions/toxicities and sequencing,

and multi-drug resistant TB. Each curriculum consists of a set of presentation slides, a Facilitator Guide,

and a Participant Handbook. Utilizing the I-TECH 5-Level Training Framework, didactic training, skill

building workshops, clinical training, clinical consultation, and technical assistance, I-TECH Botswana will

support building a training structure for BNTP training 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 second to the BNTP MOH two dedicated Master

Trainers to train and mentor Botswana clinicians using the training package developed and piloted by I-

TECH in close collaboration with BNTP and BOTUSA. BNTP in collaboration with I-TECH Botswana

developed a TB Case management training plan for Botswana; Starting April 2008, BNTP with I-TECH

Botswana support plans to train 170 Nurses Officers, 80 Medical Officers and 40 Private doctors. The target

area includes all the districts in Botswana. Funds are requested to support the two positions (one nurse and

one doctor) to be seconded at MOH, to roll out the TB trainings in the districts of Botswana and to support

0.20 FTE I-TECH Botswana Training Coordinator who will oversee this process and the two Master

Trainers. A portion of these funds will cover technical assistance and management costs for I-TECH

management in-country.

08.T1104: Clinical Profile OF HIV Infection and ARV Treatment Outcome Among Children in Botswana

Expected cost and implementation period: This is a 1-year project to conduct analysis of routinely collected

pediatric data, with an estimated cost of $100,000

Local co-investigator: Drs. Jibril (MOH); Negussie Taffa; Stephane Bodika and Disasi Kisanga (BOTUSA)

Project description: Children age below 15 years made up 9.4% of the total 85,000 people on ART in

Botswana by May 2007. The ARV program (MASA) in Botswana is far advanced in terms of patient-based

information tracking system once an individual is put on ART. The system has limited some systematic

data on pediatric care and treatment that has not been sufficiently utilized to date. This project will conduct

initial data analysis on clinical and immunological profiles of children at HIV diagnosis, disease history, and

treatment outcomes including (if available from the routine record) treatment adherence, drug side effects,

toxicities and occurrence of opportunistic infections.

Evaluation questions

1)What are the clinical profiles HIV infected children who are initiated on ARV treatment?

2)How do these profiles differ by point of entry or referring program (PMTCT, out patient clinic and routine

HIV testing)?

3)What is the level of early mortality (at 3 and 6 months) and what are the common causes?

4)What types of drug toxicities are commonly observed early and late in the course treatment for children

put on ARV therapy?

5)What are the commonly observed opportunistic infections for children on ARV therapy and what factors

are associated with OIs?

6)What are chances of survival after 2-3 years on ARV therapy?

7)What is the level of loss to follow up and treatment adherence as defined by the country's treatment

guideline?

Programmatic importance/anticipated outcomes:

Adequate knowledge of HIV manifestations, treatment outcomes and adherence issues among HIV infected

children in Botswana will inform quality care and treatment design and management. The analysis will be

used to describe the profiles of children in treatment, particularly with respect to adherence and retention,

and to develop a concept sheet for a prospective PHE to evaluate strategies to improve treatment

adherence among children who are suspected as ART failures due to adherence problems. Also part of

this initial project we will consult with other PEFPAR countries in the region who are implementing PHEs on

pediatric adherence in order to learn experiences. A third part of this initial project may be a sample record

review and abstraction from the paper-based medical records of the children receiving treatment at the 24

sites that are not linked to the electronic patient management system (IPMS). For this portion of the

evaluation, we will consult with those countries planning to conduct national pediatric outcomes evaluations

who have already developed protocols and data collection instruments that we might adapt for Botswana.

Method:

This is a retrospective record review of all children (below 12 years of age) initiated on ARV treatment

between 2003 and 2004 in six major ARV treatment hospitals in Botswana (Baylor, Nyangagbwe, Maun,

Molepolole, Selebe-Phikwe, Serowe/Palapye). These sites were among the few initial sites where pediatric

ARV treatment was started alongside the one for adults. It is believed that a complete treatment data worth

3-4 years (i.e. January 2003 to December 2007) is obtainable from the national HIV/AIDS data warehouse.

This data will be counter-checked with electronic patient records at each treatment site for completeness,

accuracy and consistency. Unique identifiers will be developed to merge data from the six sites since

children in Botswana do not have national identity numbers. Frequencies and cross-tabulations will

conducted on selected variables of interest to the study. As indicated above, the study does not involve

field data collection. Data extraction forms will be developed to address study objectives and variables.

Database managers at national HIV/AIDS data warehouse will move the information into data analysis

software of choice.

Population of interest:

Study population: All HIV infected children below 12 years of age who are on ART in public health facilities.

Information dissemination plan:

Study findings will be disseminated to health workers involved in care and treatment of children infected

with HIV in Botswana, and elsewhere as needed. Abstracts will be presented to the national and

international audiences for experience sharing.

Budget justification ($)

Salary 50,000

Equipment5,000

Supplies5,000

Travel15,000

other (contractual services): 25,000

Total 100,000

08.T1103: ITECH - Continuing Medical Education Courses

This activity continues to complement the Botswana national HIV/AIDS training program by providing

workshops on advanced topics of HIV/AIDS care and treatment. Two successful CME trainings on ARV

resistance and salvage ARV regimens, and neurological complications of HIV have been conducted. Each

session trained 75 public and private physicians.

In FY2008, I-TECH will provide another series of didactic and skill-building workshops to physicians on four

advanced HIV/AIDS topics selected by in-country clinicians. For each topic, an experienced clinician trainer

will conduct two workshops, one in Gaborone and one in Francistown. The 2008 scope of work includes

four, one-week trips to Botswana for the I-TECH expert clinical trainer. During each week of trainings, the

clinician/trainer will work with an in-country co-facilitator to conduct lectures, facilitate workshops, and

provide technical assistance to the in-country team as identified. The trainer will develop specific training

objectives prior to each training session, as the topic and audience are identified. PEPFAR funds will cover

time and travel, lodging and per diem of the I-TECH clinical trainer, training materials, training site logistical

costs, as well as a portion of overall I-TECH country management and administrative costs.

08.T1109: University of Pennsylvania

The scope and direction of the Penn - Botswana program continues to evolve. At the inception of the

PEPFAR funded program, Penn deployed one Botswana based faculty member in Gaborone with the goal

of providing high quality HIV related palliative care and treatment training to clinicians at PMH and NRH.

The program has expanded to include an outreach program to each district hospital where the goals are to

increase knowledge and improvement in the standard of patient care to those suffering with HIV/AIDS and

opportunistic infections. In 2007 with 6 specialists deployed at both referral hospitals the program will

directly influence the treatment of some 5,000 inpatients at the two referral hospitals and have an indirect

influenced on the care and treatment of some 6,000 patients at the district hospitals by having delivered

some 80 training sessions to 60 doctors under our outreach education program.

During 2007 Penn specialists have also assisted the MOH in developing their guidelines for palliative care

and will, by the end of COP07, have developed with I-TECH the clinical guidelines covering palliative care

for the MOH. In 2008 a curriculum will be compiled for the training and the service will be extended to some

periferal primary hospitals.

In patient services

Penn will have a total staff presence of four internal medicine specialists in Gaborone and two in

Francistown. They will provide inpatient care to the medical department that has a total of some 150 beds

within the two referral hospitals. However with the severe overcrowding of these beds it is expected that

these staff will deliver direct care to some 5000 inpatients suffering with HIV/AIDS and its co -infections.

As well as providing direct inpatient care Penn will also undertake a structured educational training program

aimed directly at affecting the care practices other internal medicine clinicians perform as well as a similar

program given to all clinical staff (doctors and some nursing staff) in the practice of medicine related to

HIV/AIDS. Some 250 clinicians at the 2 referral hospitals will be able to benefit from this education program.

Out patient services

During 2007 Penn started specialized HIV clinics at both referral hospitals. These clinics created a "one

stop shop" idea for patients with HIV and complications such as metabolic problems, co-morbidity issues

and co-infections that can be managed as outpatients. Clinics are run three days a week and during COP08

it is expected that some 2,500 to 3,000 patients will be managed in these specialized clinics.

Outreach services.

Botswana's 2 referral hospitals have patients referred to them by 11 district hospitals and 14 primary

hospitals. With the current HIV/AIDS pandemic, the increasing rate of OIs in patients suffering from

HIV/AIDS, the lack of clinical skills in the primary and district hospitals to manage these opportunistic

infections leads to their subsequent referral to the two referral hospitals. This is in itself is a major cause of

their overcrowding. The Penn outreach program aims at training with both lectures and direct bedside

teaching the management of patients with HIV/AIDS and opportunistic infections.

It is expected therefore that some 180 lectures will be delivered to some 60-70 primary and district hospital

doctors. This will directly affect the care of some 8,000 patients admitted to these primary and district

hospitals with HIV/AIDS and hopefully stop up to 2500 being referred to district and eventually to the main

referral hospitals in FY2008.

08.T1203: I-TECH - Laboratory Positions Support

Activity 1: Continuation of salary support for 1) Lab Scientist performing EID at Gaborone and 2) Lab

Scientist performing national quality assurance program

The International Training and Education Center on HIV (I-TECH) will be continuing with the salary support

for these 2 laboratory scientists. Costs include salary, benefits and local administration.

Laboratory Scientist placed at the Botswana-Harvard HIV Reference Laboratory

The laboratory scientist is responsible for testing infant DBS samples for early HIV diagnosis and the QA

system in the laboratory for infant DBS. The laboratory scientist also carries out CD4, viral load, and

resistance testing. The activities of this position are essential for the success of ARV treatment program in

pediatric patients.

Laboratory Scientist placed at the National Quality Assurance Laboratory

I-TECH will continue salary support for the position of one laboratory scientist at the National Quality

Assurance Laboratory (NQAL). This position characterizes proficiency testing specimens for different HIV

laboratory testing to support the NQAS; coordinates and organizes training in collaboration with the QA Unit

at MOH for lab techs; and assists laboratories in the annual proficiency testing. Shortage of staff at the

NQAL is an obstacle for quality assurance/quality control (QA/QC) implementation and rolling out of the QA

program in the country.

Activity 2: Continuation of Pre-Service Training Activities

Building upon the pre-service curriculum and training activities with the Institutes of Health Sciences (IHS) in

2007, and the technical assistance provided to explore development of the three-year program into a four-

year Laboratory Technician Bachelor's degree at the University of Botswana, I-TECH is requesting funds to

continue providing the TA to IHS and UB regarding the potential for a four-year degree program.

Activity 3: IHS capacity strengthening

In 2007 a pre-service training program was developed and PEPFAR supported the salary of five lecturers in

three district laboratories. Turnover is high and a steady cadre of trainers is not consistently available.

FY2008 funds will support three part-time trainers for these laboratories. It is anticipated that the part-time

employment may be more attractive to those with the qualifications and retention may be easier as a result.

08-X1418: I-Tech In-service Training Technical Assistance

(Change of funding mechanism from HHS/CDC New Coag (7853.08) to HHS/HRSA I-TECH (1331.08);

Change Prime Partner from TBD to Uni of Washington; Increase funding amount from 200,000 to 450,000)

08-X1418: In-service Training Technical Assistance

Since the beginning of the epidemic, the Government of Botswana has responded proactively and rapidly to

the HIV/AIDS epidemic by training health care professionals to provide HIV/AIDS prevention, treatment and

care services. In 2000, a training need assessment was conducted to inform the development of a

coordinated approach to in-service training. This laid the groundwork for the establishment of the KITSO

AIDS Training program, the national training program for HIV/AIDS care and treatment, in 2001. By

September 2006, 7,240 health care workers received theoretical and practical training in HIV/AIDS.

Despite the above-mentioned achievements, the following constraints were experienced: Roles for different

partners were not clearly stipulated; existence of many training materials and tools developed locally and

internationally targeting the same health care providers, and; absence of long-term training plan and

structure to ensure sustainability, comprehensiveness and responsiveness of the training programs.

To address these constraints, the Ministry, with USG funding, developed the KITSO Expansion Plan 2004

to guide the MOH and its training partners in the coordination of HIV/AIDS health professionals training in

Botswana. As recommended, the Department of HIV/AIDS Prevention and Care (DHAPC) established the

KITSO HIV/AIDS Training Coordinating Unit to ensure comprehensive, standardized, coordinated HIV/

AIDS training and bring all existing and future trainings under the leadership and direction of the MOH. To

further this objective, there is need to strengthen the current training system by developing training

structures and guidelines, evaluating and revising current training materials and developing new training

materials where necessary.

2008:

Conduct an assessment of existing HIV/AIDS training, training mechanisms, including the training models

(TOT, master trainers), coordination, monitoring and evaluation and the certification process; develop

appropriate structures and guidelines for the coordination, and effective implementation of in-service

HIV/AIDS-focused training

08-X1420: Existing Program Evaluations

A number of PEPFAR-supported programs have been underway for several years now. Under this activity,

external process evaluations will be conducted on activities which have been supported for three or more

years and that are planned to continue in 2008. These activities include UMDNJ-FXBC Technical

Assistance to PMTCT, Pre-service Training and Health Worker Wellness; NASTAD Technical Assistance to

Community Planning; Community Capacity Enhancement Program), and; Task shifting to lay counselors.

Based on the scope of work provided, the selected prime partner will conduct site visits and interviews with

key informants and beneficiaries of the targeted partner activities in order to identify strengths and

weaknesses of the program, and in turn, help map the way forward. The focus of the evaluations will be on

the technical content and management of the activities, as well as the effectiveness of the interventions.

Best practices and program challenges will be documented and recommendations included.