Through the funding provided by this project, the Botswana-Baylor Childrens Clinical Centre of Excellence (COE) is able to help drive the scale-up and assurance of quality pediatric and adolescent HIV care in Botswana, including increases in the number of children and adolescents accessing care and support. Training of health care providers on pediatric and adolescent treatment guidelines is a key focus of this project. The COEs activities remain important to insure universal access to comprehensive, high-quality HIV treatment services for pediatric and adolescent populations in Botswana. Refinement of direct clinical approaches; complicated case management; task-shifting; training; and dissemination of best practices to local implementers are all key components of COEs program. The TB/HIV component of the COEs activity stems from challenges facing children and adolescents with respect to access to effective diagnosis, treatment, and cure for TB. Currently only a small proportion of pediatric TB patients are diagnosed, and many health care workers lack the expertise and the experience to diagnose TB in children. The best practices developed by the COE, including its failure management clinics and Teen Club programs, are in the process of being brought to scale throughout Botswana - a key focus of the COEs ongoing efforts. As well, developing and implementing in concert with the Ministry of Health (MOH) the training of nurses in advanced HIV management is in process and is an important part of the COEs FY 2012 approach. All of the COEs programs are in the process of stepwise transition to the MOH, the National AIDS Coordinating Agency, the University of Botswana or other national entities, as appropriate and agreed between partners.

Botswana-Baylor Childrens Clinical Center of Excellence (COE) will continue to improve the scope and quality of diagnosis and treatment of pediatric tuberculosis in Botswana. This will be achieved through the training of health care workers in paediatric sputum induction and paediatric TB care and treatment. This will also be achieved through the technical support by on-site mentoring of trained health care workers at pilot sites by specially trained TB nurses and auxiliaries. The COE will spearhead the expansion of sputum induction activities as well as diagnosis and treatment of pediatric TB/HIV throughout Botswana by being involved with new sites.

Access to effective diagnosis, treatment and cure for TB patients remains a challenge for the paediatric population in Botswana. Only a small proportion of paediatric TB patients are diagnosed. Many health care workers lacks the expertise and the experience to diagnose TB in children.

There is a limited budget to train health care workers in sputum induction beyond the four pilot sites in Gaborone, Serowe, Maun, and Francistown despite the need in and interest from other sites. High staff turn-over in Botswanas national health care system results in the loss of trained personnel to other departments or facilities that do not usually perform sputum induction. This creates the need to train a new cadre of health care workers time and again. There is little we can do programmatically to maintain them in their trained function due to MOH policies. Other challenges include lost, contaminated, or mislabeled sputum samples; the impact of the public service strike in 2011; and the closure of the national TB laboratory for several months while it was being renovated.

The long-term plan is for this activity to build the capacity of health care workers through on-going training and mentorship; to increase the number of microbiologically confirmed cases of TB in children; and to integrate the current activities into the Botswana National TB Program.

Botswana-Baylor objectives for FY 2012 include 1) strengthening referral and consultation services for HIV/AIDS and TB/HIV care, with careful focus on appropriate decentralization, capacity-building, linkages, adolescent services, capacity-building with local NGO partners, and strengthening of community-based care, 2) strengthening paediatric ART failure management at decentralized sites beyond Gaborone; 3) strengthening best practices development at sites beyond Gaborone; 4) developing and strengthening additional specialized mentoring and training of nurse prescribers; 5) strengthening in-service training for health care providers; 6) expanding teacher training; 7) expanding the scope of in-reach and adolescent programs and working with the MOH toward institutionalization into Botswanas national care and treatment approach; and 8) finalizing and implementing the model for adolescent transition to adult care.

The program is aiming at scaling-up and assuring the quality of pediatric and adolescent care in the country. Through this activity we anticipate an increase in the number of children and adolescents accessing care and support. Training of health care providers on pediatric and adolescent treatment guidelines will continue to take place.

Pediatric and adolescent client numbers have increased at Baylors Center of Excellence (COE) and the outlying centers it supports through outreach. This number is increasing for those in care and support services. The outreach services have been progressing well. As the pediatric cohort graduates to the adolescent stage, Baylor is now planning to renovate an adjoining plot in Gaborone and open an adolescent center. We are developing an algorithmic model for adolescent transition to adult care at the COE. We are also rolling-out specialized mentoring in paediatric ART failure management to decentralized MOH ART sites across Botswana. We are developing recognized care best practices, including In-reach and Teen Club; communicating these to the wider care and treatment community; and rolling-out satellite Teen Clubs across Botswana.

The main challenge for in- and pre-service training has been due to economic constraints with the MOH reducing funding for training activities during the government financial year April 2010 - April 2011. The MOH obligations cover the cost of participants' travel and imprests. However, for FY April 2011 to April 2012 the MOH has availed some funding for training and we were able to reach the FY 2011 training targets. Training was also affected by the public service strike of May-June 2011.

The long-term activity plan is to collaborate with the Government of Botswana to insure good country ownership recognizing that technical expertise and capacity building in health centers is still needed. Botswana-Baylor care activities will continue a stepwise transition to the University of Botswana, MOH, and Botswana National TB Program as appropriate.

The objective of the treatment program is to scale up of pediatric ART services nationwide. We will continue to strengthen referral and consultation services for HIV/AIDS and TB/HIV with a focus on appropriate decentralization and capacity-building. By providing supportive on-site, mentorship we are able to strengthen paediatric HIV/AIDS and TB/HIV treatment through in-service training. We have assisted with the development of national guidelines on the care and treatment of HIV-positive adolescents and younger children. We continue to expand and strengthen the specialized mentoring for the management of paediatric ART failure at decentralized Ministry of Health sites. We were able to open several new failure mentoring sites in FY 2011. We expanded and strengthened best practices developed and proven at the COE over the years, including the USAID AIDSTAR-One-recognized Teen Club and In-reach programs. We pioneered additional specialized mentoring and training of nurse prescribers beyond that received in the standard national training course. The goal being to expand their scope and abilities because of the shortfall of skilled health care providers in Botswana who can scale-up and sustain the ART program.

The objectives for FY 2012 are to 1) improve the quality of care and life for children and adolescents living with HIV/AIDS; 2) reduce morbidity and mortality in this age group; 3) support quality service delivery; 4) strengthen treatment technical policies; 5) strengthen paediatric ART failure management at decentralized sites beyond Gaborone;6) strengthen best practices development at sites beyond Gaborone; 7) develop and strengthen additional specialized mentoring and training of nurse prescribers; and 8) move services closer to the people.

Pediatric and adolescent HIV treatment has long lagged behind the adult program. Pediatric and adolescent activities are important to insure universal access to comprehensive, high-quality HIV treatment services for populations in all districts and settings in Botswana. Key components of Botswana-Baylor's program are refinement of direct clinical approaches; complicated case management; task-shifting; training; and dissemination of best practices to local implementers.

Progress to date includes outstanding clinical outcomes for treatment of HIV in children and adolescents in Botswana. The diverse training programs have met many levels of community need throughout the country. The failure clinic mentoring program has been groundbreaking; its expansion to decentralized Ministry of Health sites in Botswana continues. The adolescent program has been successfully rolled-out to decentralized sites utilizing community service organization partners. Challenges include expanding the nurse prescriber corps at COE and beyond; transitioning adolescents to adult care; and dealing with the reduction in the number of specialized providers assigned to the COE. Long-term plans are focused on continuing the stepwise transition of activities to the Government of Botswana.