PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
09.C.AC13: TBD - NEW FOA for Palliative Care
The scope for this activity is to assist the Ministry of Health (MOH) of the Government of Botswana (GOB) in
providing high quality HIV-related palliative care and treatment training to clinicians at the two referral
hospitals, Princess Marina and Nyangabgwe, and further training in outreach services in palliative care to
selected district and primary hospitals. The goal is to increase the clinicians' knowledge of palliative care
and to improve the standard of patient care to those suffering with HIV/AIDS, TB/HIV and other
opportunistic infections (OI). This should have a direct influence on the treatment of inpatients at the two
referral hospitals and have an indirect influence on the care and treatment at the level of the district and
primary hospitals.
It is expected that the TBD organization will assist the MOH in developing its clinical curriculum for palliative
care for the University of Botswana's new medical school and, by the end of FY2009, will have a
comprehensive package compiled for the training and services to be extended to some peripheral primary
hospitals. The TBD organization will train health care workers and other partners according to the national
TB/HIV curricula for nurses and medical officers to ensure adherence to the Botswana National TB Control
Program (BNTP) guidelines and will provide in-service training of health care workers in the care of children
with TB and TB/HIV co-infections and, in collaboration with the BNTP, will implement strategies to enhance
the diagnosis of TB in children and improve contact tracing.
With respect to in-patient services, the TBD organization will provide inpatient care support to the medical
departments within the two referral hospitals and will deliver direct care to inpatients suffering with HIV/AIDS
and its co -infections, including patients with dual TB/HIV disease and multidrug-resistant TB (MDR-TB).
The TBD organization, in addition to the direct in-patient care services, will undertake a structured
educational training program aimed directly at enhancing the care practices of various internal medicine
clinicians' performance. A similar program in the practice of medicine related to HIV/AIDS will be arranged
for all clinical staff, both doctors and relevant nursing staff. The TBD organization will also provide pediatric
TB/HIV clinical services at the two referral hospitals for advanced treatment, consultative, outreach and
educational services for TB/HIV co-infected children and will work with all partners to strengthen linkages
between the TB and Anti-retroviral Treatment (ART) programs at the national, district and facility levels.
In terms of outpatient services, the TBD organization will run ART clinic and specialized HIV clinics at both
referral hospitals and will provide the standard of care treatment for patients with TB/HIV and MDR-TB.
These clinics will create a "one stop shop" idea for patients with HIV and other complications, such as
metabolic problems, co-morbidity issues and co-infections, which can be managed on an outpatient basis.
Botswana's two referral hospitals have patients referred to them from district hospitals and primary
hospitals. With the current HIV/AIDS pandemic, the increasing rate of opportunistic infections (OI) in
patients suffering from HIV/AIDS and the lack of clinical skills in the primary and district hospitals to manage
these OIs, lead to patients being referred to the two referral hospitals, which is a major cause of their
overcrowding. The TBD organization will provide an outreach program, using both lectures and direct
bedside teaching, aimed at training clinicians from primary and district hospitals in the management of
patients with HIV/AIDS, TB/HIV and other OIs.
New/Continuing Activity: New Activity
Continuing Activity:
Emphasis Areas
Health-related Wraparound Programs
* TB
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.08:
09.C.AC03: NEW FOA - Cervical Cancer Prevention Program
Cervical cancer is a relatively rare disease in the developed world due to organized screening and
appropriate treatment of pre-cervical cancer lesions, awareness among the general public and healthcare
workers, strong advocacy from civil society, as well as a priority on 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 more than 25% of all cancers in Botswana and
is the leading cancer in women. Of those women 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.
HIV-infected women are thought to be at highest risk for cervical cancer, due, in part, to the higher
prevalence of HPV high risk subtypes, more rapid carcinogenesis, and poor immune response.
Immune reconstitution associated with potent anti-retrovirals (ARV) does not seem to be a factor in
regression of pre-cancer lesions. If indeed that is the case, extensive availability of anti-retroviral treatment
(ART) in Botswana with associated improved life span, is likely paradoxically to permit progression of the
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.
The Government of Botswana (GOB) recognizes the magnitude of the cervical cancer problem. The
national cervical cancer prevention program currently is cytology-based following the recommendation by
the World Health Organization (WHO). Women with abnormal Pap smears are referred for colposcopy and
biopsy, and treatment of pre-invasive disease through cold knife cone biopsy, soon to include loop
electrosurgical excision procedure (LEEP), at the two referral hospitals, Nyangagbwe and Princess Marina.
Those with the early invasive disease have access to hysterectomy, while the more advanced invasive
disease is treated either for cure by radiation, specifically external beam and brachytherapy, and
chemotherapy and for palliation with radiation. With most of the health dollars committed to the fight against
HIV, however, the GOB had to look toward 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 visual inspection with acetic acid (VIA) with digital cervicography
as an adjunct and cryotherapy treatment has not been included as part of the national cervical cancer
prevention program for various reasons. Current evidence has shown that SAT, however, can be a valuable
strategy in resource limited countries, such as Botswana. As no work regarding SAT 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 SAT
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 is difficult.
Detailed Standard Operating Procedures (SOPs) will be developed, following the methodology similar to the
one used in established SAT centers, such as Zambia. This will be a one visit strategy where women
presenting to the SAT clinic will first receive counseling regarding cervical cancer prevention and the SAT
procedure, after which their consent would be obtained for cryotherapy, should it be required. In the SAT
procedure, a specially trained nurse visualizes the cervix and applies 3-5% acetic acid, before inspecting it
with the naked eye and recording the findings on a diagram of the cervix. After second application of the
acetic acid, a digital photograph (cervigram) is taken, and the image uploaded onto a laptop.
The image will be: (1) used to explain the findings to the patient;
(2) emailed to a physician for consultation where a second opinion is required; and (3) stored in database
for record keeping and used for quality control and nurse education.
Cryotherapy will be performed, if the visualized lesion fits set strict criteria.
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
Princess Marina Hospital (PMH) in Gaborone, where all patients with complex lesions will be referred. At
this clinic, patients will be examined by a gynecologist who has been trained to perform colposcopy, cervical
biopsy, and LEEP. All histologically confirmed pre-cervical cancer lesions will be treated with LEEP under
local anesthesia. Those with suspicion of microinvasion or with lesions too large for treatment under local
anesthesia will be referred to the hospital Gynecology services for cone biopsy and any further required
management, e.g., surgery, radiation and chemotherapy. The unit will also provide overall coordination and
supervision of the pilot SAT clinic, in addition to the planned clinical care.
Both the SAT and GCPU clinics will incorporate sexually transmitted infection (STI) care for women as part
of a comprehensive cervical care. A trained nurse will perform a speculum examination on the cervix with
the naked eye. If the patient is found to have significant cervicitis or a non-fungal vulvovaginitis, oral
antibiotics in keeping with the national drug formulary will be given. If a significant fungal vulvovaginitis is
identified, the patient will be given intravaginal antifungal medication. A cotton swab will be used to collect
vaginal secretions, which will be tested for pH and a wet mount made for evaluation by the nurse at the end
of the examination. All patients found to have trichomonas, bacterial vaginosis or a significant yeast
infection will receive appropriate therapy. This will be in keeping with the ethos embodied in prevention
with positives (PWP).
Activity Narrative: 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. The GCPU clinic will be situated within
PMH for proximity to other services, such as access to higher care, for example, general anesthesia and
surgery, should complications, such as hemorrhage arise.
PEPFAR will be supporting the following for the setting up of the SAT program:
Staff
The program will require a full time Obstetrician and Gynecologist(ObGyn) who will be the program director
and lead specialist with the GOB-employed ObGyn as backup, a clinical coordinator, a quality control (QC)
officer, 2 nurses at the SAT clinic, one nurse practitioner at the GCPU clinic and a data entry clerk.
The program director and lead specialist will be involved in overall project management and provide
specialist care as a clinician, teacher, and specialist resource, the clinical coordinator will coordinate training
and be responsible for data management and monitoring and evaluation (M&E) activities, as well as assist
with the running of both clinics. The QC officer will be responsible for all quality assurance issues, including
infection control, health and safety, and setting up cervicography QC meetings for cevigram- histology
correlation reviews. The nurse practitioner will run the LEEP clinic with the lead specialist and the two
nurses will be involved in the SAT clinic. The data entry clerk will be responsible for capturing data, data
cleaning and record keeping.
Training
Training of staff, which will be required at the initial phase of this pilot, will be coordinated with existing
programs that already have experience in SAT with cryotherapy and incorporate digital cervicography for
quality and evaluation. This will include a three-day didactic training workshop on cervical cancer
prevention with the trainer coming from outside the country to train all staff members, excluding the Data
Entry Clerk, that is, nurses, gynecologists, the clinical coordinator and the QC officer. Topics will cover:
background information on the female reproductive system, cervical cancer and HIV, treatment of Cervical
Intraepithelial Neoplasm (CIN) using cryotherapy, LEEP, and cold-knife, STI management, digital
cervicography, computer basics, such as emailing, indications for referral, and management of patient
records.
The three nurses will subsequently require a minimum of eight weeks practical training to gain hands-on
experience at an already established SAT clinic, for example, in Zambia, where they will be required to
perform a minimum of 100 visual examinations, 100 digital photographs, and over 30 cryotherapies. The
full time Obstetrician and Gynecologist will also require a minimum of two weeks practical training in digital
cervicography and cryotherapy.
In addition, the program director and coordinator will be trained in M&E, and the latter will also be trained in
data management. The QC officer will be trained in quality control, health and safety, and infection control,
and the data entry clerk on the program software, including data cleaning.
A Training of Trainers (TOT) model will be utilized, whereby the first trained group will be used to train
subsequent groups of health practitioners, monitored by the lead specialist and the government-employed
ObGyn.
The key to success of this program is ensuring overall quality control. All work will be implemented with
strict accordance to the SOPs and rigorous monitoring will ensure that work is of the highest standards.
Checklists will be used by all staff for their various activities and these will be routinely monitored by the QC
officer with supervision from the clinical coordinator. Immediate backup for the SAT nurses will be available
in the form of telephone and/or email consultation with the lead specialist or the government employed
ObGyn. All cervigrams will be correlated with histology results at the weekly cervicography quality control
meetings and the nurses involved will be given the opportunity to explain or defend their management
decisions.
During the initial training phase as well as during implementation, close liaison with the chosen training site
will be maintained for ongoing technical support and advice.
Program evaluation will take place at regular intervals to look at several parameters, including the number
of successfully trained staff, the number of pre-cancerous and cancerous lesions detected, and the number
of lesions treated with cryotherapy and with LEEP.
Supplies
Supplies will need be purchased and will include equipment, e.g., a cryotherapy machine, a LEEP generator
and loops, nitrous oxide gas cylinders, laptop computers, digital cameras, telephones, stationery and
stationery related services, such as printing and photocopying, bedding and consumables.
Travel
The travel expenses covered will be local between the clinics as well as regional and international.
New/Continuing Activity: Continuing Activity
Continuing Activity: 17676
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
17676 17676.08 HHS/Health University of 7713 1331.08 I-TECH $433,000
Resources Washington
Services
Administration
Program Budget Code: 09 - HTXS Treatment: Adult Treatment
Total Planned Funding for Program Budget Code: $6,902,072
Total Planned Funding for Program Budget Code: $0
Table 3.3.09:
09.T.AT13: TBD - NEW FOA for Palliative Care
09.C.TB16: TBD - NEW FOA for Palliative Care
Table 3.3.12:
