TBD was named in August 09 reprogramming.

Context

Botswana UPenn Partnership (BUP) has received PEPFAR funding since 2004, and has established programs for health-system strengthening in the management of the complications of HIV/AIDS.

BUP provides expertise in managing complex medical problems in HIV-infected individuals such as HIV-TB co-infection, multi-drug resistant (MDR)-TB, pediatrics and precancerous cervical lesions. BUP focuses on providing technical assistance through direct care and clinical mentoring, as well as case-based teaching discussions and conferences for healthcare workers at tertiary, secondary and primary hospitals and local government clinics.

BUP's pediatric program worked closely with Ministry of Health (MOH) and the University of Botswana (UB) during FY09 and has developed five guidelines. Focal diseases for Pediatrics have included TB and common opportunistic infections such as gastroenteritis and pneumonia.

Within the cervical-cancer prevention program, BUP has set up a pilot See and Treat (SAT) clinic in Gaborone, with a referral Colposcopy and Loop electrosurgical excision procedure (LEEP) clinic at the nearby tertiary hospital Princess Marina Hospital. BUP has trained healthcare workers in visual inspection of the cervix after application of acetic acid, enhanced digital imaging, record-keeping, picture manipulation, cryotherapy, colposcopy and LEEP.

BUP will collaborate with MOH to assist with the development and implementation of guidelines for common medical problems seen in HIV+ individuals. The topics include: community acquired pneumonia, meningitis, CVA, status epilepticus, diabetic ketoacidosis and hyperosmolar non-ketotic hyperglycemia, status asthmaticus, hypertensive crisis, drug overdose, congestive cardiac failure, acute cardiopulmonary resuscitation, acute confusion state, acute coronary syndrome, sepsis, acute renal failure and GI bleed and precancerous cervical lesions.

Goals and Objectives

To increase access to quality care and treatment services through building the capacity and capability of healthcare workers. BUP will do this in two broad areas adults and children.

Major Activities

The Pediatric team will work with UB and MOH to develop pediatric guidelines. An additional ten guidelines will be completed in FY10. Focal diseases include TB and common opportunistic infections such as gastroenteritis and pneumonia. The guidelines will initially be targeted at the tertiary hospitals with eventual rollout to the primary and secondary hospitals.

To facilitate implementation of adult treatment guidelines, BUP has restructured its outreach curriculum and will develop and implement 3 sets of guidelines for FY10.

BUP will give weekly conferences at current outreach sites. Mochudi, Kanye, Lobatse, and the Gaborone DHT, and monthly conferences at Tsabong, Hukuntsi, Ghanzi, Serowe, Maun, Kasane, Bobonong and Selebi-Phikwe.

BUP has advertised for an outcomes-based epidemiologist and is in the process of short-listing candidates. The epidemiologist will be appointed in FY10.

BUP will seek accreditation from the Botswana Health Professions Counsel for continuing medical education for those who attend these sessions. The cervical cancer program has already received ethical clearance from the Botswana Ministry of Health and the University of Pennsylvania.

The TB program will reinforce through direct care and clinical mentoring the National Guidelines regarding HIV-TB co-infection, MDR/XDR TB and pediatric TB. The program will provide clinical care, training and mentoring, outreach services and technical assistance to MOH regarding HIV-TB co-infection and MDR/XDR TB.

The cervical cancer prevention program will provide expert care and training in cervical cancer screening and treatment of precancerous lesions.

Enhancing Sustainability

The goals of the program were produced in collaboration with colleagues at the UB School of Medicine and MOH, including the Botswana National TB Program (BNTP), the Ministry of Local Government, and the Health Professions Council.

Monitoring and Evaluation

BUP will report on PEPFAR indicators, including data relevant to medical problems in HIV-infected individuals targeted in guideline development.

BUP will conduct operational research on various aspects of its program to evaluate impact and guide public-health policy. The enhanced diagnosis component of the Pediatric TB program is being reviewed by the institutional review boards mentioned above.

During 2009, BUP hired a data manager for all PEPFAR programs. Her current focus is working with the BNTP piloting an MDR point-of-care clinical and outcomes database.

10.C.AC03: Upenn - new FOA Palliative care, PAP Smear testing - 411,350.00

As a country that has been successful in the rollout of its national antiretroviral therapy (ART), more women in Botswana are living longer and are now at risk of other secondary conditions like cervical cancer. These conditions, if not effectively dealt with, can undermine the benefits gained through the ART program. The Botswana-UPENN Partnership Cervical Cancer Prevention Program Team has been providing cervical care to chronically infected HIV+ women in Botswana since October 2008. This pilot program utilizes the cost effective method of 'See and Treat' (SAT) where onsite screening and treatment can be offered to women accessing ART. This involves visual inspection of the cervix after application of acetic acid (VIA), with enhanced digital cervicography (EDI) as an adjunct, and cryotherapy or loop electrosurgical excision procedure (LEEP) as treatment methods. To date, 5 nurses have been trained in VIA, EDI, record keeping, picture manipulation and cryotherapy. One medical officer has been trained in colposcopy and LEEP. Detailed Standard Operation Procedures for the clinic have also been developed. Since 10 March - 30 November 2009, 1040 women have been screened using VIA/EDI. Onsite cryotherapy was done on 154 women and 184 were referred to the program gynecologist for colposcopy and LEEP. Out of the 184 women examined with colposcopy, 129 have been treated with LEEP and 12 referred for Cone Biopsy because of extensive lesions not amenable to treatment under local anesthesia. Two cancers were confirmed, with subsequent appropriate referral to, and treatment by the Gynecology department at the tertiary hospital, Princess marina Hospital (PMH). The LEEP clinic also provides treatment to patients referred via the different government clinics for management of abnormal Pap smears. Between the period of May-November 2009, an additional 229 were referred from these government clinics and were reviewed by colposcopy with a total of 166 LEEP procedures done. Twenty patients were referred for either Cone Biopsy or hysterectomy because of extensive lesions not legible for treatment by LEEP. In this group, 2 cases of invasive cancer were also identified with appropriate referral for treatment. The program goal for FY10 is to extend the colposcopy and LEEP services to Nyangabwe Referral Hospital (NRH), to cater for the northern part of the country, and train an additional medical officer in colposcopy and LEEP. The number of LEEP procedures done will be doubled in the same period. After march 2010, a program evaluation will be done to look at the numbers screened and treated in the first year with regards to estimate of impact on disease prevention. Through the program, expert advice is provided to the National Cervical Cancer Prevention Committee, especially in formulating national guidelines for screening and treatment of pre-cancer lesions. Several lectures on cervical cancer prevention have been given to various organizations including The HIV Society, The University of Botswana and other health institutions. Various members of the Cervical Cancer Prevention Team have been asked to speak at several wellness days for both government and private organizations. All these activities will continue in FY10.

10.C.AC13: Upenn - new FOA Palliative care - 900,000.00

The Botswana-UPenn Partnership HIV care and Support Team has been committed to addressing the needs of chronically infected HIV+ individuals in Botswana since 2006. This has been accomplished through a multifaceted approach of clinical mentoring of medical officers and case based discussions at the primary, secondary and referral hospitals. Teaching is centered on common medical problems affecting HIV+ individuals in the districts of Mochudi, Kanye Lobatse, Tsabong, Hukunzi, Ghanzi, Selebi-Phikwe, the Gaborone DHT clinics, Princess Marina Hospital and Nyangabwe Hospital. Botswana has been enormously successful with the rollout of antiretroviral therapy, but diseases commonly associated with aging populations such as stroke, hypertension, diabetes and coronary artery disease are increasingly seen in HIV+ individuals. There is an urgent need to build and expand local capacity to expertly manage patients with complications of chronic HIV disease and common medical problems seen in HIV+ individuals. To address this need, we will continue to collaborate with the MOH to assist with the development and implementation of guidelines for 15 common medical problems seen in HIV+ individuals. The 15 topics include: community acquired pneumonia, meningitis, CVA, status epilepticus, DKA/HNNK, status asthmaticus, hypertensive crisis, drug overdose, congestive cardiac failure, acute cardiopulmonary resuscitation, acute confusional state, acute coronary syndrome, sepsis, acute renal failure and GI bleed. Since 2006, we have also been offering technical support to the University of Botswana's Department of Medicine. Since COP09 we have increased our technical support and have agreed to assist with staffing the UB Medicine teaching service at Princess Marina Hospital, starting in January 2010. Program Goals for COP10: 1. Increasing access to quality care and treatment services and building the capacity and capability of health care workers towards the provision of quality care and treatment service delivery. To facilitate implementation of treatment guidelines, we have restructured our outreach curriculum surrounding the 15 topics (listed above) to span 47 weeks of teaching. We will continue to give weekly conferences at Mochudi, Kanye, Lobatse, and the Gaborone DHT, and monthly at Tsabong, Hukunzi, Ghanzi and Selebi-Phikwe. We will seek accreditation from the Botswana Health Professions Counsel for continuing medical education for those who attend these sessions. By the end of 2010, we project that approximately 320 lectures will be given at the aforementioned sites to approximately 80 health professionals and that there will be approximately 150 clinical mentoring sessions. There will be approximately 150 site visits, with 2,250 direct patient encounters. This will strengthen the clinical knowledge of the healthcare providers in the 15 clinical areas listed above. We will also identify goals for the educational development of the staff at each site. Once these goals have been identified, they will be assessed over the next year and plans will be made to decrease site visits depending on the percentage of goals met. Finally in partnership with the Ministry of Health, we will begin to use government transportation through Princess Marina Hospital to travel to the sites of Mochudi, Kanye, and Lobatse. Ministry-sponsored flights will continue to Tsabong, Hukunzi and Ghanzi. 2. To strengthen pre-service and in service training programs for health care workers and students in learning institutions. As part of our continued collaboration with the UB Department of Medicine, we will continue to offer technical assistance upon request to develop the Internal Medicine residency program. The program begins January 2010 with 4 residents, and we have committed to assist with staffing the teaching service. We have also offered support for their residency lecture series. We will continue to provide staffing throughout the year, offering 2-4 days per week of clinical attending time on the two teaching services at Princess Marina. This amounts to Botswana-UPenn Partnership contributing to 20-40% of the clinical teaching or 104-208 teaching encounters in 2010. By supporting the residency program, we will be contributing directly to the training of future leaders in healthcare in Botswana, strengthening its healthcare system over time. Targeted Geographical Areas: The geographic targets of our program currently include Gaborone and at the tertiary referral hospitals where specialists and subspecialists teach at conferences, and perform bedside mentoring on the inpatient medical and wards. These tertiary hospitals are the planned training sites for the UBSOM medical students and postgraduate trainees. We perform outreach to district hospitals surrounding Gaborone (Mochudi, Kanye, Lobatse). We travel to primary (regional) hospitals in the western part of Botswana (Ghanzi and Hukuntsi) as well as to Selebi-Phikwe monthly. We also perform outreach to many local clinics in Gaborone, where we lecture, mentor, and consult on topics related to HIV Care and Support. Monitoring and evaluation plans for included activities: We will continue to report on PEPFAR indicators that document the number of HIV+ patients seen and whether they are on antiretroviral therapy. In the next year, we will collect additional data on the number of HIV+ individuals presenting with common medical problems (see 15 topics, above). Additional data collected will be age, sex, CD4 count (if known), on HAART, medical officer at bedside, site and date. Data will be recorded using an excel spreadsheet and on a database that could be uploaded to the Ministry of Health. Personal health information or any identifying information will not be captured unless authorized by the Health and Research Development Committee of the Ministry of Health of Botswana. This data will be used in the context of guideline development to define the epidemiology at each district. These data will be communicated to each site and will be for reporting purposes only.

10.T.AT13: Upenn - new FOA Palliative care - 50,000.00

The aim of this activity is to increase access to quality care and treatment services and build the capacity and capability of health care workers toward the provision of quality care and treatment service delivery. To facilitate the implementation of treatment guidelines, UPENN has restructured the outreach curriculum to span 47 weeks of teaching. UPENN will continue to give weekly conferences at Mochudi, Kanye, Lobatse, and the Gaborone DHT, and monthly ones at Tsabong, Hukuntsi, Ghanzi and Selebi-Phikwe. UPENN will seek accreditation from the Botswana Health Professions Counsel for continuing medical education for those who attend these sessions. By the end of 2010, it is projected that approximately 320 lectures will be given at the aforementioned sites to approximately 80 health professionals and that there will be approximately 150 clinical mentoring sessions. There will be approximately 150 site visits with 2,500 direct patient encounters. This will strengthen the clinical knowledge of the healthcare providers in the 15 clinical areas of community acquired pneumonia, meningitis, CVA, status epilepticus, DKA/HNNK, status asthmaticus, hypertensive crisis, drug overdose, congestive cardiac failure, acute cardiopulmonary resuscitation, acute confusional state, acute coronary syndrome, sepsis, acute renal failure and GI bleed. UPENN will continue to report on PEPFAR indicators that document the number of HIV-positive patients seen and whether they are on anti-retroviral therapy. In the next year, additional data will be collected on the number of HIV-positive individuals presenting with common medical problems (see the 15 topics, above). Additional data collected will be the age, sex, CD4 count (if known), receiving HAART, medical officer at bedside, site and date. Data will be recorded using an Excel spreadsheet on a database that could be uploaded onto the Ministry of Health's system. Personal health information or any identifying information will not be captured unless authorized by the Health and Research Development Committee of the Ministry of Health of Botswana. These data will be used in the context of guideline development to define the epidemiology at each district, will be communicated to each site, and will be used for reporting purposes only.

10.C.TB16: Upenn - new FOA Palliative care - 805,000.00

The Adult TB/HIV Program of the Botswana-UPENN Partnership (BUP) began in FY06 at the Princess Marina Hospital (PMH) in Gaborone. The original scope of the program was clinical TB/HIV care, including the care of patients with drug-resistant TB (DR-TB). Over the past three years, the program has expanded both geographically and in terms of its scope. The program has identified two areas of priority to complement the Botswana National TB Program's (BNTP) strategic plan for 2008-2012: the integration of TB/HIV services and the prevention and management of DR-TB. To address these priorities, activities have expanded to include clinical teaching and mentorship, outreach services to health facilities nationwide, and technical assistance to the Ministry of Health (MOH). Program Objectives and Goals: 1. Provide clinical care to patients with TB/HIV and DR-TB: For the past three years, the BUP has managed a TB/HIV referral clinic and consultation service at the PMH. Two weekly clinics provide longitudinal care for all patients with multi-drug resistant TB (MDR-TB) in southern Botswana. One monthly clinic serves pediatric MDR-TB patients and their families in collaboration with the University of Botswana Department of Pediatrics. A third weekly clinic sees referrals for complicated TB/HIV cases from Gaborone and surrounding health districts. Referrals include patients with suspected DR-TB, adverse TB/HIV drug reactions, severe immunosuppression initiating anti-retroviral therapy (ART), and patients suffering from TB immune reconstitution inflammatory syndrome (TB-IRIS). The clinic staff provided by BUP include an infectious diseases specialist, an internal medicine specialist, a social worker, a nurse, and a health care auxiliary. Staff support provided by the PMH include the hospital TB coordinator and four medical officers on a rotating basis. A major goal is to gradually increase the proportion of care provided by MOH staff to 100% by 2014. 2. Provide consultative and outreach services to medical providers caring for patients with TB/HIV co-infection and DR-TB. The TB/HIV clinic specialists provide daily consultation services to medical providers at the PMH, including staff responsible for MDR-TB inpatients, and daily phone consultations to clinicians nationwide. Once per week, a specialist attends the PMH Department of Medicine morning meeting to discuss TB/HIV cases and teach on TB/HIV-related topics. The main goal of the BUP TB/HIV outreach services is to build the capacity of local health care workers (HCW) to provide appropriate care for patients with TB/HIV and DR-TB. Since 2007, a BUP specialist has been providing monthly outreach visits to Ghanzi, a district in western Botswana with a high prevalence of TB and MDR-TB. Outreach activities have included clinical care for MDR-TB patients, training and mentoring of clinicians in MDR-TB care and management, and didactic training on TB/HIV-related topics. Beginning in January 2010, visits will be expanded to include a full week every other month to provide additional time for training and mentoring activities. In addition, outreach services will be expanded in FY10 to another district with a high TB burden, specifically Kweneng East. Since 2008, a BUP specialist has been providing outreach services to Maun, one of the four sites identified by the BNTP as a national MDR-TB center. In 2009, BUP hired a second infectious diseases specialist and nurse to provide TB/HIV and DR-TB services to the Nyangabgwe Referral Hospital (NRH) in Francistown. The BUP specialist provides direct clinical mentoring to the NRH medical officer responsible for the care of TB/HIV and DR-TB patients, and assists with the inpatient evaluation of patients suspected to have TB. In FY10, this physician will also provide outreach services to Selebi-Phikwe, a district with a high prevalence of MDR-TB in northern Botswana. 3. Provide clinical training and mentoring for clinicians involved in the care and management of TB/HIV and DR-TB One of the major BNTP priorities is to de-centralize MDR-TB care in Botswana. To assist in this effort and strengthen the health system by building workforce capacity, the TB/HIV Clinic at the PMH was identified to serve as a training center for clinicians involved in the care and management of MDR-TB. In 2009, BUP clinic staff provided direct clinical training and mentoring for eight clinicians designated by the MOH as future providers of MDR-TB care in Ghanzi, Serowe, and Francistown. To build on the success of this initial training, BUP specialists provide on-going clinical training and mentoring for MOH MDR-TB providers in Francistown, Serowe, Ramotswa and Ghanzi. The PMH clinic also provides on-going direct clinical training and mentoring for four PMH medical officers. In collaboration with the BNTP, BUP is developing a training curriculum for health care workers who deliver DOT to MDR-TB patients and training will begin in January 2010. Finally, BUP specialists regularly assist the BNTP with TB Case Management Training, the national TB training for medical providers, by teaching sessions on TB Infection Control, DR-TB and TB/HIV co-infection. These activities are intended to build the capacity of the MOH providers who will assume complete responsibility for the care and management of TB/HIV and DR-TB patients by 2014. 4. Provide technical assistance to the MOH on issues related to TB/HIV co-infection and DR-TB. Since 2006, the BUP has provided technical assistance to the MOH on issues related to TB/HIV co-infection and DR-TB. Currently, BUP physicians serve on the MOH TB/HIV Advisory Committee and the BNTP Infection Control and MDR-TB Committees. BUP has also made significant contributions to the BNTP National Program Manual, the MDR-TB Treatment Guidelines, and the TB Infection Control Guidelines. Coordination with PEPFAR-funded partners: The BUP has a history of working closely and cooperatively with other partners to achieve its goals and objectives, and avoid duplication of services. In FY10, both the BUP and the University Research Company (URC) have mandates to improve prevention and care related to MDR-TB in Botswana. While the URC will focus primarily at the programmatic level, the BUP will prioritize clinical care, training and mentoring at facility and district levels. Close communication between the two partners will ensure minimal overlap in activities.