09.C.OV08: CRS—OVC Care and Support, Francistown

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

There has been an increase in the budget for Catholic Relief Services (CRS) to enable them to reach more

marginalized OVC. In FY2009, CRS in collaboration with the Department of Social Services (DSS) will also

focus on reaching marginalized OVC in hard to reach areas where most of the residents are from the

Basarwa tribe. The OVC will be equipped with life skills and older OVC supported with vocational training

and income generating activities.

From COP08:

Catholic Relief Services (CRS) OVC program in Botswana starts from a strong base of partnership with the

Southern Africa Catholic Bishops Conference (SACBC) and the Catholic Vicariate of Francistown. This key

partnership has allowed the rapid involvement of CRS in five districts throughout northern Botswana. The

OVC program established strong linkages with the Social and Community Development offices of the Social

Welfare Department of the Botswana Government and the Tribal Administration in all the five districts. This

partnership will continue and be strengthened to scale up the program and eventually enable communities

to support OVC in a sustainable manner.

2007 accomplishments

The OVC program benefits from linkages with regional CRS OVC programs which offer considerable

experience and lessons learned. Active involvement of regional technical advisors as well as key program

staff from other country programs has been beneficial. A total of 24 OVC leaders and program staff were

sent for a one week training program to Masiye Camp in Zimbabwe. In addition, CRS have sought out good

practices on youth and community led programming as well as AB resources. These efforts expand service

to three and seven years old age groups in the northern districts of Botswana to enroll them in pre-school

and assure attendance. CRS addresses the needs of OVC ages 8-17 through the development and

support of OVC community level support activities. CRS linked with The Regional Psychosocial Support

Initiative for Children Affected by AIDS, poverty and conflict (REPSSI) specifically to explore the use of their

Journey to Life program. This program aims to support both caregivers and children through workshops

which encourage, not only reflection and dialogue, but also action to better meet the needs of vulnerable

children.

The program linked with SOS Children's Village and Light and Courage Centre to collaborate in experience

sharing and training for youth and field staff. The program will collaborate with Program Concern

International (PCI) who are in the process of starting a program in Botswana.

2008 plans

The program will scale up its activities and reach 6,000 OVC in 13 parishes in the Catholic Vicariate of

Francistown. The program also aims to reach 13,000 indirect beneficiaries. Activities will build on program

accomplishments and capacity and will continue to strengthen services, leadership roles and livelihoods

opportunities for the existing and proposed OVC program participants. 2008 plans will target 71 villages.

Enrollment of OVC in preschool will continue in the existing 27 preschools reaching 460 OVC. New

preschools will be identified to reach a total of 600 OVC. Block grants will include school fees, clothing,

meals for children, and improvement of facilities and services. Up to 100 OVC leaders and 100 community

leaders will be identified and trained to lead the initiation and implementation of community support

activities. The leaders will receive initial training through participation in the Masiye OVC support trainer of

trainer's camp in Zimbabwe.

The specific program activities will be defined individually for each village and will engage peer groups,

caregivers, community volunteer, and civil society organization, such as the Village Development

Committees, teachers, and other local government officials. The OVC leaders and community leaders will

receive additional support through exchange visits and training and workshops to be organized and

sponsored through the program, in collaboration with Salvation Army, REPSSI, Social Welfare Department

and NGOs involved in OVC programming. The trainings will include topics on HIV/AIDS prevention, Life

Skills, Behavioral Change Process, Leadership skills, etc. Support and training for the caregivers will be a

critical element for the successful expansion of the program.

Activities undertaken by OVC and community leaders include: establishment of weekly psycho-social

support groups with facilitated discussions designed to address the needs and concerns of OVC and how

caregivers and communities can help create an enabling environment for OVC livelihoods development;

awareness building on OVC rights; learning about government services and how communities can help fully

utilize these services; improvements to a community based structure to be used for meetings and events;

development of awareness building and IEC materials.

The program will target 710 OVC who have dropped out of secondary school or have finished school and

have limited opportunities for livelihood activities, and no opportunity for higher education. Activities will

include visits from working professionals, vocational schools and teachers intended to expose and inform

OVC about various professions and to inspire interest. Program staff will identify a volunteer in the village

to collect career resource materials such as job announcements or job market studies and organize a

central place in the village where this information can be accessed. With assistance and materials from

program staff, the volunteers will organize discussion and learning sessions on how to learn more about

potential jobs, prepare a C.V., make contact, and apply for opportunities. Each OVC will also be supported

to either enroll in a short training course or work as an apprentice with an experienced professional. One

possible activity could be to carry out a Participatory Livelihoods Assessment with affected OVC and the

community.

Activity Narrative: CRS will support the capacity building plan of the Vicariate by obtaining external trainers (e.g. HIV/AIDS

training for the Clergy is planned for November 2007) and through specific trainings using tools and

manuals developed in-house by CRS technical staff. The in-house trainings may include: program

management and monitoring and evaluation; finance management and budgeting training; advocacy

training using the CRS advocacy training manual. CRS will dedicate technical advisors within the southern

Africa region or globally who will lead these in-house trainings.

New/Continuing Activity: Continuing Activity

Continuing Activity: 17654

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

17654 4899.08 U.S. Agency for Catholic Relief 7839 3527.08 GPO-A-00-04- $875,000

International Services 0008: OVC:

Development Support to

OVCs Affected

by AIDS

10188 4899.07 U.S. Agency for Catholic Relief 5419 3527.07 $499,000

International Services

Development

4899 4899.06 U.S. Agency for Catholic Relief 3527 3527.06 $499,000

International Services

Development

Program Budget Code: 14 - HVCT Prevention: Counseling and Testing

Total Planned Funding for Program Budget Code: $7,943,642

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

In response to the challenges that HIV and AIDS present to Botswana, efforts continue to be made to diversify approaches, fine

tune technical support, and plan for future program sustainability with the support of the Presidents' Emergency Plan for AIDS

Relief (PEPFAR). The national HIV prevalence rate is 23.9% among adults ages 15 to 49, according to recent UNAIDS data, and

an estimated 300,000 are living with HIV/AIDS. About 53.2% of Batswana know their HIV status up from 25% in 2004, 95% of

pregnant mothers gaining that information through the Prevention of Mother to Child Transmission program. The Botswana 2007

Sentinel Survey indicated that HIV prevalence among pregnant women (15-49 years) is 33.7%, though the overall trend appears

to be decreasing from 37.4% in 2003. The Department of HIV/AIDS Prevention and Care reports that, as of the end of July 2008,

a total of 109,991 patients were receiving HAART, 97% of the 113,000 patients estimated to require treatment. Challenges

remain, however, with prevention, particularly the issue of multiple concurrent partnerships, alcohol abuse, nascent civil society,

and human capacity development.

Statistics

Up through FY2008, the United States Government (USG) supported the counseling and testing (CT) program of the Government

of Botswana (GOB) through procurement of rapid HIV test kits, training, social marketing, non-governmental organization (NGO)

capacity building, increased service delivery sites, pilot testing of innovative approaches, such as door-to-door voluntary

counseling and testing (VCT), the Care-for-the-Carers program, development of policy and guidelines, and monitoring and

evaluation activities. In 2007, over 310,000 tests were performed: Tebelopele VCT centers counseled and tested 126,329 clients

(42.3% of whom were first-time testers), government facilities tested and counseled over 170,000, and other civil society

organizations (CSO) counseled and tested over 11,000 clients. It is now estimated that 53.2% of Batswana know their HIV status

up from 25% in 2004 and 18% in 2001. In 2009, the target is to perform over 387,000 tests, representing a 25% increase over

2008 numbers. Scale up will be done by the addition of CSOs with CT services, the training of more lay counselors and the

strengthening of routine HIV testing (RHT). About 41% of the tests undertaken in 2009 will be directly funded by the USG, while

the others will be indirectly supported through guidelines, training and monitoring and evaluation activities.

Services

Traditional VCT is provided by a network of organizations, including Tebelopele VCT centers, other NGOs and community-based

organizations (CBOs), and government facilities that are available throughout Botswana, covering the two major cities, namely

Francistown and Gaborone, and the other main towns and villages. A rapid assessment by the Ministry of Health (MOH) in 2007

identified the parts of the country not adequately covered, such as the Okavango and Kgalagadi districts. Six CBOs in these

districts were selected for the President's Emergency Plan for AIDS Relief (PEPFAR) support through the MOH to improve

service delivery. To further strengthen the capacity of CSOs to provide high quality VCT services, a twinning partnership is

operating between Tebelopele and Botswana Christian AIDS Intervention Program (BOCAIP), and the Liverpool VCT in Kenya

and The AIDS Support Organization (TASO) in Uganda.

Provider-initiated Testing and Counseling (PITC) or Routine HIV Testing (RHT), launched in 2003, is offered in all 28 health

districts in Botswana. In 2008, PEPFAR provided technical support and funding for strengthening RHT through the adaptation of

the Centers for Disease Control and Prevention (CDC) curriculum for PITC. The University Research Corporation (URC) was

engaged to provide support to the MOH and the Ministry of Local Government (MLG) in strengthening RHT using a district level

process improvement model, an activity that USG will support in FY2009.

CT is largely provided using rapid HIV tests with same-day results. A parallel rapid HIV testing algorithm is used with HIV testing

being performed by a spectrum of health professionals, including well trained and supervised lay counselors. The GOB through

the Central Medical Stores (CMS), supplies rapid HIV tests to both government and civil society sites, although supplies can be

inconsistent with occasional "stock-outs." Supply Chain Management Systems (SCMS), began strengthening the CMS for

improvement of the whole supply chain management process for C&T in 2007. Alternative rapid HIV tests are currently being

evaluated to allow for variety of rapid test kits and it is anticipated that the rapid test algorithm will change slightly in 2009.

VCT outreach expanded in 2007 from mainly mobile caravans and work place services to "door-to-door" pilot VCT programs in

Bobonong and Selebi-Phikwe districts, "ward-based" VCT in Ghanzi district, VCT in the bus and taxi ranks in Gaborone and

Francistown, as well as VCT in the churches and shopping malls. In 2008, Tebelopele VCT center introduced "moonlight" testing,

largely targeting farm workers in the Ghanzi area who do not have time to test during the day and Commercial Sex Workers

(CSW) in the Kasane (Botswana-Zambia-Zimbabwe) border area. Clients are mobilized by members of the local Post-Test Club

(PTC). In FY2009, Tebelopele plans to reduce outreach services by 50% because their current key strategy is to build the

capacity of community-based organizations in various areas of the country to assume direct service delivery in order to enhance

the sustainability of CT services in the future; however, mobile and satellite services will continue, especially to targeted

populations, such as prisoners and farm workers.

The results from the pilot door-to-door testing will be disseminated in FY2008 and will inform any revisions in the project protocol.

It is envisaged that in FY2009, door-to-door testing will be rolled out in Selebi-Phikwe and Bobonong, with funding from FY2007.

Social marketing and community mobilization has been intensified to target more couples and men to test. Testing campaigns

included the Tebelopele's "Passport to Life," "Couples who test together stay together," "Show you care," Zebras4Life, Test4Life,"

and "Life Fest" aimed at specific population segments. Volunteers meeting specific criteria set by the MOH are being trained as

lay counselors to provide additional manpower for CT services.

In 2007 and 2008, post-test services were established in the VCT sites throughout the country and through the twinning

partnership, Liverpool VCT provided technical support to Tebelopele in the establishment of 16 Post Test Clubs (PTCs). In

collaboration with the local and CDC-based Prevention Teams, the CDC "prevention package," which provides on-going

supportive and prevention counseling for use in clinical settings was adapted for the VCT sites. This prevention package

specifically includes materials used for providing additional support to VCT clients who test HIV positive as well as their partners.

It covers critical issues, including partner testing, disclosure, and consistent and correct condom use. Based on feedback from the

counselors, the materials are being adapted for use with the PTCs. Additionally, a questionnaire screening both HIV negative and

HIV positive clients for TB has also been introduced at the VCT centers in collaboration with the TB/HIV programs and the MOH.

Quality assurance and monitoring of CT continues in collaboration with BOTUSA's laboratory and the MOH. In 2007, over 200

nurses, professional and lay counselors were trained to perform the rapid HIV tests. Civil society sites put in place quality

assurance measures, such as proficiency testing, proper storage facilities, temperature monitoring and proper record keeping.

The MOH is currently revising the Monitoring and Evaluation (M&E) tools with the view of standardizing these across the country.

The revised tools, which include an HIV Testing and Counseling (HTC) register, will be launched by end of 2008. Training of

Counselors and other providers in CT is being carried out by institutions with curricula that have been approved by the Ministry of

Health.

Based on previous progress and learning, FY2009 funds will largely support the consolidation of on-going activities, the sharing of

best practices towards sustainable CT services, the increased involvement of the media and private sector and the efforts aimed

at increasing access of CT to men, youth, children, couples and high-risk groups, such as CSWs. In 2008, URC was engaged to

support the GOB and key stakeholders in developing training curricula and protocols for scaling up child and adolescent CT and

strengthening the implementation of RHT in the districts. In collaboration with the prevention, care and support, TB/HIV and

PMTCT program areas, the President's Emergency Fund for AIDS Relief (PEPFAR) funds will support on-going Prevention with

Positives (PWP) interventions with a focus on discordant couples. The "National Testing Month," in October 2008, will be

replicated in 2009. Additionally, Botswana proposes to participate in multi-country public health evaluation of interventions for high

-risk HIV negative clients.

Referrals and Linkages

In 2007, Tebelopele VCT centers transitioned from anonymous to confidential VCT services, a change that enabled follow-up of

clients between the VCT and clinical sites when over 75% of clients provided their names and national ID ("Omang"), though the

option of anonymous services is still available. The referral form for clinical services now includes information from the TB

screening of clients and all clients, HIV-negative or -positive, symptoms suggestive of TB are referred for evaluation, but no

current data exist on the efficacy of this system. Referral networks of HIV/AIDS service agencies operate in the various locations

where the VCT sites are with the aim of providing a continuum of care. Through the PWP project, clients are offered follow-up

support services at VCT sites, including support groups of people living with HIV/AIDS (PLHWA) and information on government

facilities.

In 2008, CSOs worked with volunteers and Community Home Based Care (CHBC) groups to strengthen referrals from community

to government settings in order to improve linkages between community and government sites. For example, Humana People to

People implemented a tracking system in July 2008 that involves the issuing of cards to traditional healers and other key people in

the community to refer clients and patients to HIV/AIDS care, treatment and support sites. Thus far, 160 cards have been issues

and 31 have followed up on the referral. Members of the PTC, volunteers from the Tebelopele youth against AIDS program,

counselors from other CBOs, and PLHWA support groups are all providing additional support in following up and linking clients

with various services in the continuum of care.

Policy

The age of consent for HIV testing being 21 is still a major barrier for CT. Discussions are still going on to reduce the age of

consent from 21 to 16, as recommended by the National AIDS Council and, at this point, the issue is at the Parliament level. In

2008, USG and WHO/AFRO supported the on-going efforts by the MOH to review and update national guidelines for CT, which

are now in the final review stages at the MOH management level and will be launched by end of 2008. Policy and guidelines for

CT of children and adolescents are also being developed in 2008, along with training programs and protocols for providing

services for these age groups.

Tebelopele has successfully adapted the Assess Consent Test Support (ACTS) protocol in the VCT centers, which the MOH has

approved and plans to adapt for use throughout the country. This protocol greatly reduces the counseling time, largely by

providing group pre-test information to clients as they wait to be tested; thereby reducing the time each client spends individually

with a counselor.

Challenges

The following remain the key challenges to the CT program area:

•Legal age of consent at 21 is still very high and poses a challenge to providers.

•Referral procedures are not monitored or followed up.

•PITC or RHT is still weak in terms of support supervision, mentoring of lay counselors and inadequate human resources for

service provision.

•More women are reached than men, especially in the government facilities, CT is still inaccessible in many hard-to-reach

locations in Botswana due to difficult terrain, long distances, sparse population and language barriers and services for high-risk

groups, such as CSW and truck drivers are inadequate.

•Stigma is believed to prevent some people from accessing services.

Table 3.3.14: