Result: Improved Management and Implementation of the PMTCT Program

Inputs

Through an existing Cooperative Agreement for the expansion of PMTCT, the USG will continue to support

the positions created in the national and regional PMTCT program and other related Ministry of Health

departments (AIDS/STD Unit, Technical Support Services and Institutes of Health Sciences). These are

"project posts" and are not permanent civil service positions.

The following positions will be supported through funding:

•National Coordinator 1

•Regional Coordinator 2

•Counseling officers 3

•IEC officers 3

•Nutrition officer 1

•Data manager 1

•Data entry clerks 2

•Lab Scientist 1

•IHS Training coordinator 1

•Psychosocial Support coordinator 1

Activities/ Outputs

All vacant positions will be filled and all will continue to be supported.

New activities include:

•Four sub-regional PMTCT workshops to train 120 senior health care workers

•Procurement of an ELISA machine and accessories for the Jubilee laboratory in Francistown to improve

the turn around time of HIV testing

Outcomes

The expected benefit will be strengthening of the national PMTCT human resource capacity and laboratory

support to address the critical human capacity shortages and provide for effective implementation of the

PMTCT program including expanding the role of and training for nurses and midwives.

July 11, 2005: $250,000 added to this approved 2005 COP activity to (a) maintain a less intensive IEC

campaign with production of materials done by local organizations with less overhead costs and, (b)

undertake additional training.

July 13, 2005: $150,000 taken away from this activity for the purchase of emergency infant formula to

respond to an acute public health crisis.

Result: increased effectiveness and reach of prevention messages

Inputs: The USG will provide funding and technical assistance.

Activities/Outputs: The AIDS/STD unit within the MOH conducts several HIV/AIDS and STI related

activities, e.g., monitoring and evaluation, surveillance, training, information, and education & counseling.

Salaries will be provided for 3 positions in MOH (one surveillance officer and two counseling officers) and

the strengthening of an HIV/AIDS hot-line call center. For the hot-line call center, the support will be used to

further promote the hot-line and utilization of it by various programs in and out of government, monitor caller

profiles and topics to assess utilization by the public, and provide training and equipment to strengthen the

call center's capacity to answer calls and provide appropriate responses.

Outcome: Utilization of the call center by HIV programs in and out of government will increase, and call

volume from the general public will rise. Government capacity to respond to the HIV/AIDS epidemic will be

sustained.

Result: training of adult and pediatric palliative care provided to health workers including nurses, community

-based service providers and family caregivers

The USG will provide financial and technical assistance to Government of Botswana/MOH/AIDS/STD Unit

to support two palliative care specialist positions, as well as support activities to review and revise adult and

pediatric palliative care policies and service delivery guidelines, to develop training curricula, to deliver

training to community-based and clinic-based health care providers, and to improve linkages between clinic

-, community-, and home-based care.

Input: The USG will provide financial support, as well as facilitate technical assistance from regional and

international palliative care experts.

Activities / Outputs: The first specialist will facilitate review of existing policies and guidelines for palliative

care, and will develop training curricula and facilitate the training of five master trainers and 280 service

providers in collaboration with the palliative care sub-unit. In addition, the specialist will develop a plan for

rolling out training in key districts nationally through the master trainers. The second specialist will plan and

conduct training on the management of opportunistic infections among PLWHA, using existing materials

based on revised clinical guidelines, reaching 1,000 clinicians, nurses, and community health care workers

in clinical settings across Botswana.

Outcomes: Palliative care policies and guidelines will be strengthened. Training programs in palliative care

will be established, addressing a key gap in the health care system. A core cadre of health care providers

will be trained to deliver high-quality palliative care services, improving health care delivery for PLWHA.

Results: IPT for prevention of TB provided in all districts with full monitoring and evaluation; enhanced HIV

testing of TB patients; integration of HIV surveillance and services with TB programs.

Input: The USG will provide funds and technical assistance to the MOH.

Activities/Outputs: This activity will support the IPT program through human resources, training, and

strategic information; monitor utility of isoniazid for IPT through drug resistance survey among MTB isolates;

integrate TB/HIV surveillance and services through training, strategic information and development of

policies and guidelines; promote HIV testing among TB patients through training and strategic information.

Outcomes: Delivery of TB palliative care services will be strengthened.

July 11, 2005: $250,000 added to this approved 2005 COP activity to (a) organize more district level

training after the national TB/HIV surveillance course, (b) implement HIV testing for TB patients nationwide,

(c) review of the national TB/HIV program (d) refer co-infected HIV/TB patients for appropriate treatment

(ARVs and Anti TB drugs) and, (e) account for initial under budgeting.

Result: improved ability of caregivers and service providers to support holistic health care for children

The USG will provide funds to enable the establishment of a rehabilitation unit for malnourished children

infected with HIV/AIDS in two referral hospitals (Nyangabgwe and Princess Marina), which will serve as a

model care center and provide on-site training for caregivers and health care workers. The center staff will

also develop training materials and facilitate training-of-trainers activities to develop a cadre of master

trainers, and a plan for roll out of ongoing training.

Inputs: The USG will provide financial and technical assistance to the MOH, who will distribute resources to

the national hospitals.

Activities/Outputs: The MOH will support an expert in the field of child nutrition, to set up rehabilitation units

in Nyangabgwe and Princess Marina hospitals. These units will serve as model care centers, and will

provide training opportunities through clinical rotations. Within the unit, children's caregivers will receive

information and instructions about home care. In addition, training modules for pediatricians and dieticians

will be developed. Through training-of-trainers activities, a cadre of master trainers will be developed with

the goal of conducting ongoing training for health care providers across the nation.

Outcome: The establishment of these units will enable the efficient management of malnourished children at

both of Botswana's' national hospitals, and reduce hospital admissions due to HIV malnutrition.

Result: Increased access to and availability of VCT; improved quality of HCT services through development

of national service delivery guidelines, quality assurance and standardized monitoring and evaluation tools;

Strengthening the capacity of FBO/CBO/NGOs to provide VCT services

Input: Through a cooperative agreement with the MOH, the USG will provide funding and technical support

in the expansion of counseling and testing services through integration into the existing services of

FBO/CBO/NGOs. Due to limited capacity, the MOH, through competitive bidding, will sub-contract an

umbrella organization that will be responsible for identification of FBO/CBO/NGO organizations suitable for

adding VCT into their work through a rapid needs assessment, and for administering smaller grants to those

organizations. The USG will also support the MOH in the development of national guidelines, service

delivery standards and monitoring and evaluation tools for HCT including VCT, routine HIV testing and

supportive counseling.

To enhance the capacity for meeting demand for RHT in the public facilities, the USG will fund the

procurement of HIV rapid tests by the MOH (Technical Support Services). The USG will also support the

MOH in the adoption of the curriculum for couples HIV counseling and testing (CHCT) currently near

completion by HHS/CDC, and the training of a core country team of CHCT trainers based in various

HIV/AIDS training institutions.

Activities/Outputs: The umbrella organization, in collaboration with the MOH, will coordinate the training of

two additional counselors for each of about six community-based organizations, procurement of HIV test

kits and supplies, renovation of exiting facilities for HCT, and monitoring of quality of HCT services provided

by those organizations. Counseling and testing protocols used at the Tebelopele VCT centers will be

modified and adopted to the NGO situations. Counseling centers supported by Global Fund will be targeted

to add on the testing component, where they meet the required minimum standards. Geographical areas

and populations that are currently deprived of VCT centers/facilities will be prioritized. VCT and RHT

service delivery standards and monitoring and evaluation tools will be developed and disseminated for use

by all facilities. Referral linkages will be created between these agencies and government ARV sites by

developing referral forms and procedures within and among the service agencies and creating a forum for

periodic discussion and coordination of referral linkages.

Outcome: Through expanding counseling and testing services to community-based organizations,

development of guidelines, strengthening of capacity for couples CHCT, and procurement of rapid HIV

tests, more people will be able to receive counseling and testing with same -visit results, as well as referral

to community groups for ongoing support services. With more people learning their status and more

organizations providing VCT, stigma and discrimination will be reduced and capacity for ongoing provision

of VCT services will be enhanced.

Results: security system installed at Central Medical Store (CMS); facilities in the districts supplied with

ARVs that are available and accessible to HIV/AIDS patients; suppliers for drugs and dressings for

HIV/AIDS identified; CMS staff trained in supply chain management and quality assurance for ARVs and

related medical supplies

Input: The USG will provide funds.

Activities/ Outputs: The MOH will use $1,164,409 in funds from the USG to supplement the procurement of

drugs and related supplies so as to increase the availability of these drugs and increase the number of

people accessing ARVs. The MOH will use funds from the Emergency Plan to engage a contractor to

procure and install security systems at CMS and facilities in the districts. This will ensure that these drugs

are kept safe and that only the intended people benefit. On training activities, the MOH will use the USG

funds to train CMS staff on supply chain management and quality assurance. This will cover 20 CMS staff

who are involved in procurement, distribution and quality assurance of ARVs to cover 100% of the country.

The MOH will further use the USG funds to engage a contractor to expedite the identification of experienced

and capable suppliers for the Central Medical Store. The identified suppliers will be recognized by GOB for

the efficient procurement of ARV drugs and their timely delivery by respecting the principle of the

"5Rs" (right quality, right price, right quantity, right time and right place)

Outcome: These activities will ensure a safe and stable supply of ARVs in Botswana.

Result: Trained staff in good manufacture, inspection and pharmaco-vigilance

Input: The Ministry of Health will use USG funds to train two D.R.U. staff in good manufacture practice,

inspection and pharmaco-vigilance to ensure that quality of ARV drugs and opportunistic infection drugs is

maintained.

Activity/ Outputs: The trained staff will strengthen the inspection rate and carry out scheduled inspections

and conduct training of trainers to cover the whole country. The recipient will improve transportation of staff

to conduct scheduled inspections nationwide.

Outcome: This activity will improve performance in good manufacture practice and allow staff to conduct

efficient inspection and pharmaco-vigilance resulting in maintained quality of ARV and opportunistic

infection drugs in the country.

Results: improved laboratory space capacity at identified sites; national laboratory quality assurance system

operationalized

Input: The USG will provide financial assistance through a cooperative agreement with the MOH Technical

Support Services Department to improve laboratory capacity to support the National ARV program.

Activities/ Outputs: The beneficiary will be responsible for:

-developing and implementing, with Botswana laboratory experts, laboratory users, and external laboratory

partners, a three year plan to upgrade laboratory services;

-assuring coordination and provision of laboratory services to support Emergency Plan activities

-developing and implementing policy for laboratory testing and quality assurance

-assuring that a service technician (or service) is available to maintain laboratory equipment

-providing continuous education and training in basic quality assurance and quality control practices

-providing external quality assurance (via proficiency testing, on-site auditing and retesting of a portion of

samples tested by HIV rapid tests);

-providing refrigerators and freezers where needed

-providing supplies and reagents to support expanded testing needs for ARV

-remodeling laboratory space where needed

-purchasing temporary structures (porta-cabins) to meet crisis needs for additional laboratory space

-assuring that the MOH is adequately staffed to meet expanded quality assurance needs

-updating the curriculum and student load at HIS to increase the stream of new technologists and

-sponsoring annual scientific meetings and workshops to further professionalize laboratory medicine and

service.

Outcomes: The activities will ensure laboratories have increased space capacities, improved quality

assurance, well maintained laboratory equipment, a continuous supply of reagents and improved standard

of practice of trained staff.

Result: expand the health information network

Expansion of the Integrated Patient Management System (IPMS)

Input: The USG funds will contribute to the expansion of the Integrated Patient Management System (IPMS)

from the current 19 (4 hospitals & 15 clinics) to 23 facilities. All of the newly planned IPMS sites will be

hospitals. The MOH has placed a high priority on the implementation of this system due to its critical role in

improving flow of patients in the Infectious Disease Control Centers (IDCC), expediting follow-up of

HIV/AIDS patients on ARV Therapy, in facilitating decision making to assess patients' eligibility for ARV

therapy, and determining utilization of skills and materials. Inputs will be resource requirements (manpower,

drugs, space etc).

Activities/Outputs: MOH IT Division will be responsible for tendering and managing the Meditech contract to

acquire software licenses and configuration of IPMS in additional facilities. MOH IT Division will purchase

the necessary hardware required to support the implementation. IPMS will be configured for implementation

in four hospitals. The required hardware and networking will be installed prior to implementation. IPMS will

be deployed in four hospitals containing ARV clinics. There will be nine functional modules supporting

health services to HIV/AIDS patients. 400 healthcare workers operating in the four hospitals will be trained

in using the IPMS.

Outcomes: IPMS will improve the effectiveness of managing patient care and treatment for HIV/AIDS

patients. It will provide clinical and managerial staff with accurate and timely information that will support

improved resource deployment and more efficient.

Result: expand HIV surveillance to underreported populations and integrate it with STIs

Annual Antenatal Care sentinel surveillance

Inputs: The USG will provide funds and technical assistance.

Activities/Outputs: There is a plan to strengthen the resource base of the surveillance unit at AIDS/STD unit

in the MOH such that the unit will be able to resume undertaking annual antenatal sentinel surveillance of

HIV/STI, which was managed by NACA for the last four years. One epidemiologist will soon join the

existing two public health specialists in the unit. There is need to recruit one data manager and two data

clerks. The unit must strengthen its logistics capacities by procuring more computers, data storage

software, printers, etc. The epidemiologist will plan and conduct sentinel surveillance in pregnant women

and males with STIs. S/he will be responsible for all aspects of data management, including analysis and

dissemination of the results. District integrated disease surveillance staff, at least two in each district, will be

trained on data collection and reporting. The AIDS/STI unit in the MOH will collaborate with all stakeholders

particularly HHS/CDC/BOTUSA for technical assistance. A portion of the funds will support additional

technical assistance for a 2005 ante-natal surveillance activity and the rollout and implementation of routine

HIV testing in STI clinics.

Outcomes: At the end of FY 2005, it is expected that the HIV/STI surveillance unit in the MOH will be well

resourced and fully operational. The staff in all districts will be able to properly undertake sentinel

surveillance. The availability of annual HIV/STI sentinel surveillance data is the overall outcome such that

the country will be able to continually monitor trends in HIV and STI prevalence.

Note that the AIDS/STI Unit is another implementing partner for integrated TB/HIV surveillance activity

which is addressed in the palliative care/TB section of this document.

Results: obtain baseline information on the quality of HIV/AIDS services in the country

Health Service Provision Assessment (HSPA) of quality of care in HIV/AIDS services

Botswana has one of the largest numbers of people living with HIV in the world. Botswana has embarked

on an ambitious ARV program which is currently serving about ten percent of PLWHAs in Botswana who

are eligible for ARV treatment. Improving the quality of life for PLWHAs through better clinical and palliative

care services forms a cornerstone of HIV/AIDS activities in the country as more and more people live longer

years with the illness. Botswana has never conducted baseline HSPA to monitor changes in quality of care

for HIV/AIDS although the ARV therapy that was rolled out nationally in 2001.

Inputs: The USG will assist in funding national HSPA in collaboration with the MOH AIDS/STI Unit and

capable international consultants experienced in undertaking such surveys.

Activities/Outputs: Representative samples of public and private (for-profit and non-profit) facilities engaged

in HIV/AIDS prevention, treatment and care activities and their personnel will be collected and studied.

Outcomes: The study will assess the situation of health infrastructure and knowledge and skills of health

workers. Proxy-indicators of treatment and care service outcomes will also be assessed.