The Botswana Harvard Partnership (BHP) program has two goals: 1) to improve identification, care and treatment of children exposed or living with HIV and/or TB and 2) to build capacity of the Government of Botswana to respond to HIV through training. A new activity in FY 2012 is a research study entitled An Analysis of Risk Factors for Adverse Pregnancy Outcomes among HIV-infected and HIV-uninfected Women in Botswana and 2-year Infant Mortality by HIV Exposure, PMTCT Prophylaxis Strategy, and Feeding Method. The first part of the protocol has already been completed and results disseminated in-country. The second part of the protocol involves a prospective study to follow HIV-exposed and HIV-unexposed infants for two years to identify risks for early mortality. High infant mortality, particularly among HIV-exposed infants, is a concern in Botswana. This study will describe two year morbidity and mortality among children in Botswana who are HIV-unexposed, HIV-exposed but uninfected, and HIV-infected. It will also describe survival by infant feeding strategy among HIV-exposed and HIV-unexposed children and HIV-free survival by PMTCT strategy among HIV-exposed children. Study findings will inform policy decisions regarding obstetrical and neonatal management, antiretroviral use in pregnancy, and early infant feeding recommendations for HIV-infected women. These findings will be applicable to other countries as well when disseminated through conferences and publications. This activity is in keeping with the GHI strategy which is focused on women and acceleration of results through research and innovation.

In Botswana TB/HIV and MDR-TB remain conditions of public health concern with evidence of progress increase in MDR-TB prevalence. For the Pediatric population access to effective diagnosis, treatment and care continues to be a challenge.

The objective of BHP Pediatric HIV/TB Management activity within the BHP Pediatric program is building capacity of health care workers through on-going training and mentorship to improve management of children with TB and TB/HIV co-infection, through collaboration with the National TB Program and other stakeholders. To achieve this BHP has been involved in the review and refining of the existing screening algorithm for TB diagnosis in children, as well as review and provision of current information, education and communication materials for adolescents and parents of children with TB/HIV co-infection. BHP staff will continue to provide training of health care workers on pediatric TB case management; undertake joint support supervisory visits for M & E; facilitate training of laboratory personnel on TB microscopy at peripheral labs and integrate pediatric TB care with community support mechanisms

A new activity in FY 2012 is a two year infant mortality study examining HIV exposure, PMTCT prophylaxis strategy, and feeding method. Study findings will inform policy decisions regarding obstetrical and neonatal management, antiretroviral use in pregnancy, and infant feeding recommendations for HIV-infected women in Botswana and other countries as well.

This study will enroll newborn infants at 4 locations in Botswana: Francistown; Maun; Mochudi; and Ramotswa. Two additional locations may be added in the future, depending on accrual: Molepolole and Gaborone. Children will be followed until 24 months of age. Before discharge from the maternity ward to home, women will be approached by trained research assistants and asked to consent for basic follow-up of their child every 3 months until 2 years of age. This follow-up will occur either by direct contact or by a scripted cell phone interview.

In total, we will enroll 3,000 infants and follow them through 2 years of age. Enrollment will be restricted to 1,500 infants born to HIV-infected women, and 1,500 site-matched infants born to HIV-uninfected women. At birth, we will collect maternal and child demographics; maternal HIV status; and pregnancy and birth characteristics (including antiretroviral exposures). Infants born to HIV-infected women will have a heel-stick dried blood spot HIV PCR which will be stored for later testing if the child is found to be HIV-infected or if untested. Mothers who tested HIV-negative within the past 6 months will be asked to repeat HIV testing as available per Botswana government protocol. HIV-infected women who qualify for a CD4 or viral load test will be encouraged to receive this through the government, and results will be recorded. In addition, all women will have a finger stick for filter paper dried blood spot storage, for later viral load, genotyping, or HIV testing if required.

At 1, 3, 6, 9, 12, 15, 18, and 24 months of age, infants will be followed by trained research assistants who will complete a 10-minute questionnaire that includes vital status of the child and mother, hospitalizations, feeding method, infant HIV status, and PMTCT prophylaxis method if applicable. We will also capture geographic and seasonal information for all outcomes. This will occur by calling the cell phone number(s) provided. Mothers or caregivers who cannot be located will be scheduled for direct follow-up by research assistants.

The goals of the study are to 1) to describe 2-year mortality among children in Botswana who are HIV-unexposed, HIV-exposed but uninfected, and HIV-infected; 2) to describe HIV-free survival by maternal PMTCT strategy among HIV-exposed children; and 3) to describe HIV-free survival by infant feeding strategy among HIV-exposed children.

The pediatric program goals are to 1) improve identification of and the care and treatment for children and adolescents exposed or living with HIV and/or TB and 2) build the capacity of the Government of Botswanas HIV/AIDS response through collaborative training. The pediatric program has provided site support and clinical mentoring, in-service lectures, set up pediatric treatment failure registries, contributed to the pediatric TB algorithm, offered telephone support for pediatric queries, and followed up with sites for initiation of positive HIV results. The pediatric program has also provided clinical mentoring and lecturing for the new University of Botswana School of Medicine residents. Training has lagged behind due to non-completion of the adolescent HIV training manual and changing of almost all HIV-related programs necessitating material review and updating. The program should get on track this financial year. Botswana Harvard AIDS Institute will continue to support capacity building in all segments of pediatric HIV/AIDS treatment and care through updating of knowledge of best practices, providing pediatric clinical training, mentoring, and supporting health personnel to ensure that minimum required standards of care are continually met. With HAART, more HIV infected children are entering into adolescence. Issues relating to adolescent care have assumed prominence. Although there are no clearly defined adolescent treatment guidelines, limited adolescent focused programs exist to address this emerging need. Botswana Harvard AIDS Institute in collaboration with other stakeholders will 1) develop a framework that comprehensively addresses adolescent HIV/AIDS treatment; 2) train ARV nurse prescribers and dispensers on pediatric HIV/AIDS treatment; 3) mentor and support the adolescent ART program; 4) complete the adolescent treatment and care training manual for health care providers; 5) train health care providers on the completed manual; and 6) coordinate access to other existing community-based adolescent resources and programs though integration of services.