The Botswana Harvard Partnership (BHP) is developing a sustainable training capacity in clinical care and treatment of HIV; expanding CD4, viral load, and other laboratory testing; and strengthening the Ministry of Health (MOH) monitoring and evaluation (M&E) capacity for HIV. The Clinical Master Trainer (CMT) Program provides on-site training and mentoring and telephone support. These activities ensure that health professionals are up-to-date in all aspects of HIV treatment and care, improve their skills on a continuous basis, and receive technical mentoring. The CMT Program is also responsible for the introduction of new treatment guidelines for HIV-infected women in the national PMTCT program. BHP will provide training, mentoring and support to health workers in all districts in the country on these new guidelines. A new activity for CMT in FY 2012 is assisting in the national roll out of universal HAART for pregnant women. The Laboratory Master Trainer (LMT) Program was developed to support the goal of establishing decentralized laboratories capable of performing CD4, viral load, and other tests to relieve the countrys two National HIV Reference Laboratories. Seven laboratory master trainers are providing training in conducting these tests, using a similar site support approach as the CMT Program. The goal is to create adequate capacity at the local level for laboratory tests. BHP supports the M&E Unit in the MOH through seconded staff. The strategic aims of the program are for the MOH to 1) support e-health and the Global Health Initiative, 2) develop and deploy country-owned, sustainable information systems, and 3) provide information to improve programs.

Botswana Harvard AIDS Institute continues to strengthen the National M&E system of MOH through strategic secondment of nine PEPFAR-funded information management staff to DHAPC and 16 data entry clerks to healthcare facilities. These officers have in turn led the development of M&E within DHAPC and supported other departments within MOH. Key successes from the previous year include 1) the development and deployment of an integrated electronic patient information management system (e-registers) for ART, PMTCT, Sexual and Reproductive Health, HTC, pharmacovigilance; appointment booking; and stock management to five districts, 2) mentoring and IT support to train both facility-based health practitioners, local IT support staff, and district M&E Officers on the use and maintenance of the electronic patient information management system, 3) reporting to national and international organizations 4) progress made on the development of e-registers for nutrition and child health, and 5) demonstrated the use mobile phone messaging for appointment reminders and laboratory result notifications. MOH policy supports integration and delivery of quality information for program management, performance monitoring, and evidence-based policy-making. MOH has a strategic objective to improve information, communication, and technology by maximizing utilization of available resources and by improving information management and research. It intends to do this through implementation of e-health and integration of existing health information systems. During FY 2012, the M&E Unit with support from PEPFAR will continue leading the development of M&E tools, indicators and reports for all programs within DHAPC and explore integration opportunities with other MOH departments such as Department of Health Policy Development Monitoring and Evaluation (DHPDME) and Department of Public Health (DPH) within MOH. The focus of these efforts has been the ARV, PMTCT, HTC, SMC and CHBC programs. Standard M&E tools are nearly final and are aligned with NACAs M&E Framework for the National Operational Plan 2011-16. PEPFAR funds will be used to further develop and expand the DHAPC data warehouse to enable ministry-wide health data to be captured and integrated. Currently, patient-level electronic data are being collected on a quarterly basis from ART facilities and BOMAID and then integrated in the DHAPC data warehouse using computer programs developed by the M&E team. PEPFAR will support the development, deployment, and support for e-registers to the remaining 24 health districts and their interface with mobile phone messaging systems; auditing and training on data quality and development of procedures and tools for data quality management; and development and coordination of a quality management program for the health sector response to HIV/AIDS. The M&E Unit will also continue transitioning from PEPFAR funded staff to Government hired employees for sustainability. Leadership, management and coordination roles are being transitioned to the M&E coordinator hired in April 2011. Skills to develop and manage the data warehouse are being transferred to a GOB employee. Data entry clerks will be absorbed by GOB.

This is a new activity for the Clinical Master Trainer (CMT) program. The objective is to train health care providers on the provision of PMTCT universal HAART and guide implementation in selected districts. Activities will include a) the development of training materials in line with the new national ART treatment and PMTCT guidelines; b) printing of training manuals; c) selection of the sites for universal HAART for PMTCT; d) training of health personnel from the selected districts; e) site support, clinical mentoring, coaching, and supportive supervision for newly trained sites and the original phase one sites; f) coaching PMTCT program staff on the guidelines and supportive supervision of MOH facilities; g) training health care workers (HCW ) on use of the PMTCT registers in the electronic medical record system; and h) facilitating monthly reporting based on the reporting tool for PMTCT. This activity is in line with PEPFARs goal to increase PMTCT coverage and effectiveness and to heighten linkages with family planning and safe infant and young child feeding practices. It also supports a primary goal of the second phase of PEPFAR which is focused on building the capacity of partner countries to respond to HIV/AIDS effectively. As recommended in the PEPFAR guidance, there is a renewed effort on the integration of programs such that efficiency and continuum of care for HIV-infected pregnant women and their infants are ensured. The project also focuses on women, which is in keeping with GHI objectives. Anticipated challenges include ensuring that HCW are adequately trained and empowered to give appropriate counseling messages regarding infant feeding in the background of HIV. The new PMTCT guidelines allow for breastfeeding with the use of antiretroviral prophylaxis. This is a new concept for health care providers in Botswana who have traditionally recommended that HIV-infected women formula feed. Changing the mindset of these HCW will be challenging.

In FY 2011 the Clinical Master Trainer (CMT) program trained 672 health care workers (HCW) on anti-retroviral therapy (ART) and palliative care service delivery. These included 41 HCW in AIDS clinical care fundamentals, 230 HCW in introduction to AIDS care, 258 HCW in ARV prescribing for nurses, 113 HCW in ARV dispensing for nurses, and 30 HCW in pharmaco-vigilance. CMT supported and mentored 32 hospitals and >120 ART clinic sites. The ART nurse training curriculum was completed. CMT fielded an average of 600 calls for telephone support per quarter. The Laboratory Master Trainers (LMT) added two additional labs for CD4 counts and seven labs for viral load bringing CD4 labs to 23 and viral load labs to 17. CMT trained 41 laboratory technicians on the current laboratory manual (three were trained centrally and 38 were trained on-site) and ten laboratory technicians were trained on TB microscopy. One lab assessment was done for upgrading. The External Quality Assurance (EQA) program continues and the lab training curriculum has been completed. All 23 CD4 and 17 viral load laboratories are being supported. The CMT will continue to 1) train nurse dispensers and prescribers; 2) train health care providers on implementation of quality assurance activities at ART sites; 3) provide continuing medical education at the district level and telephone support; and 4) continue development of training materials for the roll out of the universal PMTCT HAART program and failure management. The LMT will continue to 1) provide support for CD4, viral load, hematology, chemistry , and microbiology; 2) train on Laboratory Information System issues related to data management, reagent logistics, and quality assurance; and 3) support External Quality Assurance (EQA) activities. Challenges in FY 2011 included the track 1 transition for BHP which included funding and restructuring issues and the government-wide strike which affected training plans.