PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Subdivisions of Program Areas, these track general higher level sub-classifications of expenditure.
Subdivisions of Major categories, these are the most detailed expenditure data.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008
In 2005, through USG support, the HHS/CDC/BOTUSA completed the development of a computerized
PMTCT monitoring system and installed it at the national PMTCT offices in the MOH. This system, based
in Epi-Info, was to be rolled out to the districts in FY06 to improve the capacity for monitoring PMTCT
program implementation and quality of care. In anticipation of the roll out of the system,
HHS/CDC/BOTUSA trained 24 PMTCT focal persons and Peace Corps Volunteers (PCVs) in M&E.
However, due to critical human resource shortages at the MOH, including the absence of a data manager,
the rollout was suspended. The absence of a data manager also resulted in a lack of supervision and
guidance on data entry into the database at the MOH, as well as on data collection at the clinic level.
Overall, this resulted in a lack of reliable data for PMTCT program monitoring, and for policy making and
guidance. In 2007 MOH PMTCT Unit was able to hire a Data Manager and the PMTCT Unit was
supported in terms of data quality management. In January 2008, the Data Manager had resigned, leaving
the Unit again without support for activities around implementing, piloting, roll out trainings. This new
activity is intended to improve human capacity and quality of data relating to PMTCT, with the emphasis
areas of strategic information, human resources and local organization capacity building. The activities to
support the PMTCT strategy are:
1. Human capacity development for the PMTCT Unit: Hire and second to MOH/PMTCT a data manager:
Grade: D2 @$40,500 per annum = $54,000 (including salary, benefits, etc)
Justification for the Position
This position will supervise two data clerks and be responsible for the PMTCT information systems, M&E.
The position is stationed in Gaborone at MOH.
2. I-TECH Training Coordinator - $54,000 per annum @ 10% time
This position will contribute to the overall efficacy of the training portions of this project
In collaboration with the entire PMTCT team, I-TECH will provide ongoing mentoring and team building
among the national PMTCT team. In addition, I-TECH will assist the program to establish mechanisms and
procedures for data quality control, and take necessary steps to ensure data reliability. This component will
compliment the Botswana government's effort in building human resource capacity to manage the PMTCT
program both at the national and district levels. Train 16 PMTCT Unit MOH staff in SPSS. ($50,000)
2. PMTCT data quality: Complete, accurate, and timely data are critical in M&E the PMTCT program. I-
TECH will pilot the PMTCT data collection forms in 4 districts with MOH guidance, and based on the
findings revise the tools. I-TECH will roll out the tool in all 24 districts; train health care workers (including
PMTCT District Coordinators) in all the districts on the new tool; Develop and Conduct a data audit,
immediately following the introduction of the new system; Create and maintain a system for regular audits of
3. EID (Early Infant Diagnosis): Starting November 2007, I-TECH is assisting the MH/PMTCT Unit with data
collection for the EIS program- this activity needs to continue as at this point in time, MOH is not ready
given the shortage of human resources to take on this activity. ($50,000)
A portion of these funds will cover technical assistance and management costs for I-TECH in-country.
08.C0610: I-TECH - STI Syndromic Management
Between 2004-2007, the International Training and Education Center on HIV (I-TECH) successfully
supported the MOH National STI Training and Research Center (NSTRC) to implement the revised
Sexually Transmitted Infections (STI) syndromic management training, including the introduction of
acyclovir for genital ulcer disease, to all districts nationwide. Training in syndromic management of STIs
includes routine HIV testing (RHT) of clients as well as risk reduction counseling. In 2007, I-TECH began
supporting the NSTRC to implement clinical mentoring among their district trainers and health care
In 2008, I-TECH will continue to support the NSTRC to scale up clinical mentoring to the remaining districts
through training of clinical mentors and providing support to trainers during the initiation of clinical
mentoring. PEPFAR funds will be used to develop and reproduce a clinical mentoring guide (training
materials) for all district trainers (27 trainers including master trainers), as well as support partial time and
travel of the I-TECH Quality Improvement (QI) Specialist who is developing this training and supporting the
NSTRC with the scale out.
I-TECH will assist the NSTRC to strengthen the Supportive Supervision Visits conducted. In 2007, there
were 3-4 supervisory visits in 14 districts conducted by the district trainers who were trained by Master
Trainers. The plan is to conduct supervisory visits into the remaining districts (10) and maintain the quality
of mentoring and training in the initial 14 districts.
2008 funds will support four staff at the NSTRC until such time as the MOH is able to absorb these positions
and hire them directly. These include:
- STI Master Trainer at D4 level
- STI Training Coordinator at D3 level
- STI Master Trainer/M&E Officer, all continuing from prior years and
- STI Data Clerk, part time to be supported with 2008 funds.
2008 funds are also requested for MOH/NSTRC staff development, specifically funding the study tour costs
for the MOH/STI Training Coordinator and two other STI Master Trainers from implementing districts to
attend the University of Washington's Principles of HIV & STD Research Course in July 2008.
The I-TECH funded STI Master Trainers are responsible for supporting the district trainers with their
supportive supervision visits, responding to efforts to improve the quality of care, and reporting on the visits.
One of these Master Trainers will also be responsible for scaling up use of acyclovir to the remaining
districts (ten additional districts in Phase 3), providing support to the trainers and pharmacy technicians in
the scale up, and monitoring the correct prescription and stock levels at district clinics and hospitals.
I-TECH will provide technical assistance to the NSTRC on integrating their monitoring activities into the
MOH's overall M&E and surveillance activities. The I-TECH funded Master Trainers will work with the
NSTRC coordinator and clinic staff, administration, Central Medical Stores (CMS), and other stakeholders
to improve the quality of STI care.
2008 funds are requested to support half the salary and relocation costs of a M&E Technical Lead to be
based in the Gaborone office, as well as partial time and one trip for I-TECH (Seattle-based) QI Specialist to
work with the I-TECH M&E Lead to build the capacity of the MOH/STI program with in-service training, how
to enter, analyze and interpret data to result in evidence-based planning activities. I-TECH will conduct
individual training assessments of the STI unit staff in order to tailor training based on individual need and
conduct this training accordingly.
Additional printing of the STI syndromic management training materials (1,000 Participant Handbooks) will
be needed to provide for two additional years' worth of training.
08.C0609: University of Pennsylvania - Palliative Care Services Support
The scope and direction of the Penn - Botswana program continues to evolve. At the inception of the
PEPFAR funded program, Penn deployed one Botswana based faculty member in Gaborone with the goal
of providing high quality HIV related palliative care and treatment training to clinicians at PMH and NRH.
The program has expanded to include an outreach program to each district hospital where the goals are to
increase knowledge and improvement in the standard of patient care to those suffering with HIV/AIDS and
opportunistic infections. In 2007 with 6 specialists deployed at both referral hospitals the program will
directly influence the treatment of some 5,000 inpatients at the two referral hospitals and have an indirect
influenced on the care and treatment of some 6,000 patients at the district hospitals by having delivered
some 80 training sessions to 60 doctors under our outreach education program.
During 2007 Penn specialists have also assisted the MOH in developing their guidelines for palliative care
and will, by the end of COP07, have developed with I-TECH the clinical guidelines covering palliative care
for the MOH. In 2008 a curriculum will be compiled for the training and the service will be extended to some
periferal primary hospitals.
In patient services
Penn will have a total staff presence of four internal medicine specialists in Gaborone and two in
Francistown. They will provide inpatient care to the medical department that has a total of some 150 beds
within the two referral hospitals. However with the severe overcrowding of these beds it is expected that
these staff will deliver direct care to some 5000 inpatients suffering with HIV/AIDS and its co -infections.
As well as providing direct inpatient care Penn will also undertake a structured educational training program
aimed directly at affecting the care practices other internal medicine clinicians perform as well as a similar
program given to all clinical staff (doctors and some nursing staff) in the practice of medicine related to
HIV/AIDS. Some 250 clinicians at the 2 referral hospitals will be able to benefit from this education program.
Out patient services
During 2007 Penn started specialized HIV clinics at both referral hospitals. These clinics created a "one
stop shop" idea for patients with HIV and complications such as metabolic problems, co-morbidity issues
and co-infections that can be managed as outpatients. Clinics are run three days a week and during COP08
it is expected that some 2,500 to 3,000 patients will be managed in these specialized clinics.
Botswana's 2 referral hospitals have patients referred to them by 11 district hospitals and 14 primary
hospitals. With the current HIV/AIDS pandemic, the increasing rate of OIs in patients suffering from
HIV/AIDS, the lack of clinical skills in the primary and district hospitals to manage these opportunistic
infections leads to their subsequent referral to the two referral hospitals. This is in itself is a major cause of
their overcrowding. The Penn outreach program aims at training with both lectures and direct bedside
teaching the management of patients with HIV/AIDS and opportunistic infections.
It is expected therefore that some 180 lectures will be delivered to some 60-70 primary and district hospital
doctors. This will directly affect the care of some 8,000 patients admitted to these primary and district
hospitals with HIV/AIDS and hopefully stop up to 2500 being referred to district and eventually to the main
referral hospitals in FY2008.
08.C0603: I-TECH/Uppen- Improved PAP Smear Testing
Cervical cancer is a relatively rare disease in the developed world due to organized screening and
appropriate treatment of pre-cervical cancer lesions, awareness amongst the general public and healthcare
workers, strong advocacy from civil society, as well as prioritization of women's health issues in these
countries. Women in poorer countries face problems of limited access to care, highlighting the inequity
inherent in this disease.
There are close to 500 000 new cases of, and 275 000 deaths from cervical cancer world wide, with 80% of
these occurring in resource-limited settings. Twenty percent of all annual global deaths from cervical cancer
occur in Sub-Saharan Africa. Cervical cancer accounts for > 25% of all cancers in Botswana, and it is the
leading cancer killer in women. Of those presenting with cervical cancer in Botswana, 90% of them have
never been screened.
Persistent infection with oncogenic types of HPV is essential for development of invasive cervical cancer.
Risk factors for persistence occur more frequently in resource-limited countries like Botswana.
HIV infected women are thought to be at highest risk for cervical cancer. This is thought to be due in part to
the higher prevalence of HPV high risk subtypes, more rapid carcinogenesis and poor immune response.
Sub-Saharan Africa is the epicentre of the world AIDS epidemic, contributing 35% of all people with AIDS,
32% of all new infections and 32% of all deaths. Out of a population of 1.7 million in Botswana, there is an
estimated 270 000 people living with HIV. Prevalence rates for HIV in Botswana are currently ~ 28% in
women in the 15-49 age group, by extrapolation, a large proportion of Batswana women can therefore be
assumed to be at increased risk of pre-cervical cancer lesions and possible invasive cervical cancer, thus
making this a new public health crisis next to TB, in Botswana.
Of the 270 000 people living with HIV in Botswana around 110 000 qualify for ARV right now. The
Government of Botswana has spearheaded the fight against HIV/AIDS, by developing the first national anti
retroviral therapy (ART) programme in Africa, launched in January 2002. To date around 85% of those
requiring treatment are receiving it.
Immune reconstitution associated with potent anti-retrovirals does not seem to be a factor in regression of
pre-cancer lesions. If indeed that is the case, then, extensive availability of ART in Botswana with
associated improved life-span, is likely to paradoxically permit progression to cancer in more women.
Taking all these factors into consideration, it is becoming clear that cervical cancer is rapidly becoming a
secondary epidemic in the wake of HIV in Botswana.
When Botswana gained independence from Britain in 1966, the country was rated as one of the 25 poorest
in the world. Just over 3 decades later Botswana status changed, and the country is now classified as a
middle income economy. This has been due to a combination of prudent use of diamond derived wealth,
sound democratic processes as well as proper governance structures which resulted in rapid economic
However, the impressive gains made in Botswana's human development have been seriously threatened by
the HIV/AIDS pandemic, and this is evidenced by notable deterioration of major social indicators such as
child and maternal mortality rates. Hence the decision to implement a national ART program, but that has
meant that most of the development resources were diverted.
Elevation of Botswana to a middle income status coincided with this decision, and this signaled to the
traditional donors to either scale down or pull out their resources dealing, a double blow to a nation already
reeling from unprecedented loss of productivity and skilled human resources, especially in the 24-49 age
The government of Botswana recognizes the magnitude of the cervical cancer problem. The national
cervical cancer prevention program currently is cytology based following recommendation by the World
Health Organisation (WHO). Women with abnormal Pap smears are referred for colposcopy and biopsy,
and treatment of pre-invasive disease is through cold knife cone biopsy (and soon to include loop
electrosurgical excision procedure -LEEP) at the 2 referral hospitals (Nyangabwe Referral Hospital- NRH in
the north, and Princess Marina Hosital- PMH in the south). Those with early invasive disease have access
to hysterectomy. More advanced invasive disease is either treated for cure by radiation (external beam and
brachytherapy) and chemotherapy, and for palliation with radiation. However, with most of the health
dollars committed to the fight against HIV, Botswana had to look at her development partners for assistance
to scale up the cervical cancer prevention program, especially with regards to HIV infected women.
The ‘See and Treat' (SAT) method using cryotherapy has not been included as part of the national cervical
cancer prevention program for various reasons. However, current evidence has shown that ‘See and Treat'
can be a valuable strategy in resource limited countries such as Botswana. As no work regarding ‘See and
Treat' with cryotherapy has ever been done in Botswana, we are proposing to have a pilot program to test
the suitability and acceptability of this technique in HIV infected women attending a local clinic in Gaborone.
If the technique can be shown to be acceptable in Botswana, the results will be shared with government and
the method could be advocated for inclusion in the national cervical cancer prevention program, specifically
targeting women in rural areas where follow up would be difficult.
Lessons learned in Zambia from their SAT cervical cancer prevention program, indicate that a minimum of
40% of HIV infected women would not be suitable for cryotherapy and therefore need alternative treatment
with LEEP. As part of the program, a Gynecologic Cancer Prevention Unit (GCPU) will be set up at PMH in
Gaborone. As well as clinical care, the unit will also provide overall coordination and supervision of the pilot
‘see and treat' clinic.
Both the SAT and GCPU clinics will incorporate sexually transmitted infection (STI) care for women as part
of a comprehensive cervical care. This will be in keeping with the ethos embodied in prevention with
Activity Narrative: The initial phase of this pilot will require training of staff in visual inspection and cryotherapy, as well as
The SAT clinic will be located at one of the local primary clinics within Gaborone. This will be one of the
sites where HIV infected women are assessed for eligibility for ART, but with no access to cytology based
screening (not all the primary care clinics in Gaborone provide routine cervical cancer screening for
women). The GCPU clinic will be situated within PMH for proximity to other services such as access to
higher care (general anesthesia and surgery) should complications such as hemorrhage arise.
The procedure to be followed at each clinic will be detailed in the standard operating procedures to be
developed. Women presenting to the ‘see and treat' clinic will be counseled regarding cervical cancer
prevention and the procedure of speculum examination and visual inspection with acetic acid, and consent
obtained for cryotherapy should it be required. During speculum inspection, women will also be assessed
for STI and appropriate treatment guidelines followed should there be evidence of cervical or vaginal
infection. Aceto-white lesions will be recorded, followed by digital cervicography for objective record
keeping, distance consultation as well as part of monitoring and evaluation. All aceto-white lesions will be
assessed using cryotherapy eligibility guidelines for cryotherapy treatment suitability. Those meeting the
criteria for treatment will be offered same day treatment.
Women with lesions not suitable for cryotherapy, or requiring further assessment, will be referred to the
GCPU clinic where they will get a full gynecological assessment, including colposcopy, biopsy and LEEP.
STI assessment will also be part of the assessment. Those with invasive disease will be referred to the
hospital's gynecology services for further management (surgery radiation and chemotherapy), as has been
PEPFAR will be supporting the following for the setting up of the SAT program:
Staff for the See and treat and LEEP clinic will need to be trained in visual inspection with acetic acid,
cryotherapy, cervicography and LEEP. Training will also be provided for diagnosis and treatment of STIs.
This will include equipment, both heavy (eg cryotherapy machine, LEEP generator and loops, nitrous oxide
gas cylinders, laptop computers etc) and light, stationery, printing, photocopying, telephones, bedding and
08.C0703 University of Pennsylvania
The Penn HIV/TB program was initiated in April 2006 at PMH with PEPFAR funding, with the goals of
strengthening the care of HIV/TB co-infected persons in Botswana through training and education, clinical
consultation and collaboration with the BNTP. More than one third of all TB patients in Gaborone are
diagnosed at PMH.
It is estimated that a quarter of the 2,000 children admitted each year to NRH in Francistown are co-infected
with HIV/TB. NRH has a critical shortage of pediatric specialists: only 6 of the 10 pediatric specialist posts at
NRH are currently filled. This number includes 2 rotating pediatricians from the Baylor Center of Excellence
and an expatriate pediatrician who will be leaving Botswana in late 2007. Each year NRH pediatricians
attend to 2,000 in-patients, 2,000 HIV-infected children in the outpatient HIV clinic and provide limited
outreach work to 4 district hospitals and 12 primary care hospitals.
PMH admits more than 2,000 children per year, 10-20% of whom are co-infected with HIV/TB. There are
only 4 pediatric specialists, including 2 Baylor pediatricians. PMH is the pediatric referral center for 5 district
hospitals and pediatric specialist outreach by the Baylor Pediatric Team reaches 4 of these hospitals. This
proposal will provide pediatric specialist outreach to the fifth, Ramotswa Hospital.
In FY2007, the Penn TB/HIV program implemented changes within the reporting systems at PMH to ensure
collection of relevant information, improved TB-HIV surveillance within the facility, improved transition to
district directly observed treatment strategy (DOTS) and eventual referral for ART. During this period, the
PMH IDCC provided care to 266 HIV-TB patients, including 20 with multidrug-resistant TB (MDR-TB).
During the same period, 27 HIV-TB patients were initiated on ART, while 67 TB patients were diagnosed in
other wards and departments at PMH and referred for ART at the IDCC.
The Penn TB/HIV program conducts clinical didactic teaching and clinical mentoring at four district hospital
sites in the greater Gaborone area. The program trained 190 health care workers in TB-HIV palliative care
issues, and participated at BNTP training workshops held in Gaborone for 60 medical officers working in all
hospital facilities in Botswana (three 2-day workshops held in Gaborone, including one exclusively for
Penn is collaborating with I-TECH to develop new national TB/HIV training curricula for medical officers and
nurses. Penn is actively collaborating with the BNTP to develop and implement a national strategy for MDR-
TB management, and contributed to the finalization of the national TB management manual which was
finalized with FY2007 support.
It is proposed to continue with the 2007 activities of providing treatment, consultative and educational
services for HIV/TB co-infected patients, training of 180 health care workers in collaboration with the BNTP
and I-TECH according to the new TB/HIV curricula for nurses and medical officers to ensure adherence to
BNTP guidelines, and strengthening linkages between the hospital and the national TB and ART programs.
It is proposed to continue with the subspecialty HIV/TB clinic at PMH and to provide TB treatment to 180
HIV-infected clients with TB disease (particularly those patients with drug-resistant TB), HIV counseling and
testing to 600 registered TB patients, and clinical prophylaxis for TB to 200 HIV-infected individuals. The
Penn TB/HIV program intends to refer 600 patients for DOTS in the Gaborone City Health Clinics, and to
refer 90 TB patients for HIV care at local IDCCs.
The baseline proportion of HIV-infected IDCC clients screened for TB infection in 2007 will be evaluated
and it is intended to improve the proportion by 5%-10% in 2008. It was determined that approximately 90%
of TB patients are offered screening for HIV. The targeted rate for 2008 will increase this by 5%. In 2007,
only 50% of HIV/TB co-infected patients at PMH had baseline CD4 testing. It is intended to improve the rate
by 10%-20% in 2008.
It is proposed to increase the TB/HIV program by adding one full-time specialist and one nurse to do TB/HIV
co-infection work at PMH at a cost of $110,000. Specific areas that require more staffing include: clinical
work; infection control at PMH; outreach to the City Council Clinics and Primary Hospitals; greater
involvement in developing and implementing a nationwide TB training program; expanded participation on
ministry related committees, task forces and workshops.
It is proposed to form 2 TB Support Teams (TB teams) of lay persons trained to carry out basic diagnostic
and reporting functions for the enhanced management and diagnosis of TB and TB-HIV. Health care
workers (HCWs) are overburdened, in short supply and are currently responsible for most activities related
to TB control in the health facility. Therefore, trained local technical staff could help TB diagnosis and follow-
up. The hospital-based TB team would be comprised of two individuals (with nurse and physician backup)
who will 1) conduct simple symptom screens on all admitted medical patients to identify TB suspects; 2)
collect sputum specimens from all identified TB suspects (expectorated or induced samples); 3) transport,
retrieve and report on all specimen results to the appropriate health care teams caring for the individual
patients; 4) perform rapid bed-side HIV testing on all TB-suspects with no known HIV result; 5) submit
serum for CD4 T-cell testing on HIV infected patients; 6) initiate access to HIV and TB services for identified
A second TB support team will be based in the City Clinics and will have a similar composition with the
primary responsibility of ensuring specimen collection and reporting of all TB patients during TB treatment
(at 2 months to initiate consolidation of TB therapy in those responding to treatment and at 6 months to test
for cure). All Gaborone City Clinics will be monitored with the goal of scheduling follow up visits at the
various clinics on different days of the month such that the TB team can see all the patients. The cost for
the TB support teams will be $80,000.
Nyangabgwe Referral Hospital, Francistown
PEPFAR funds will be used to recruit two pediatric clinical specialists to advance treatment, consultative,
outreach and educational services for HIV/TB co-infected children in Francistown. Activities include
increasing the capacity to deliver care to HIV/TB infected children in both the in- and out-patient settings at
Francistown with outreach services to all the city clinics. PEPFAR will train 15 medical officers in the
Francistown area in the care of children with TB and HIV/TB co-infection through case-based discussions
and didactic lectures. Two nurses and two social workers will be recruited to initiate a pilot contact tracing
program at PMH, focusing on 2 key areas: (1) children admitted to PMH with TB, and (2) HIV-TB co-
infected adults at the Penn-Botswana IDCC clinic who have children. USG funds will support the training of
30 medical officers and pediatricians at PMH, Ramotswa Hospital, NRH, Maun and Kasane Hospitals on
contact tracing of patients with TB and HIV/TB co-infection.
At PMH, a cough team composed of one nurse and one nursing assistant will be formed to collect samples
from children (gastric washing or induced sputa), take samples to the laboratory, and follow up on all results
via a detailed log book. This pilot project to enhance the diagnosis of TB in children has the potential for
expansion to other district hospitals. To coordinate data entry, it is proposed to recruit one data manager.
The Botswana-Penn Adult HIV/TB program began at PMH in April 2006 with FY06 support. The program
has subsequently expanded and continues to build local infrastructure to improve the care of HIV/TB
infected adults. USG funds will support the Penn-Botswana Program and their pediatric partner, The
Children's Hospital of Philadelphia (CHOP) in strengthening the pediatric partnership between PMH, NRH
Based on the Botswana National TB guidelines and program manual, I-TECH Botswana developed a
training package for Medical and Nursing Officers. The curricula include content on TB diagnosis, TB
prevention and infection control, contact tracing, complexities of clinical management, Anti Tuberculosis
Treatment (ATT); Treatment of the dually infected patient; drug-drug interactions/toxicities and sequencing,
and multi-drug resistant TB. Each curriculum consists of a set of presentation slides, a Facilitator Guide,
and a Participant Handbook. Utilizing the I-TECH 5-Level Training Framework, didactic training, skill
building workshops, clinical training, clinical consultation, and technical assistance, I-TECH Botswana will
support building a training structure for BNTP training program to purposefully and incrementally develop
capacity among Botswana health care providers to manage the clinical complexity of TB-HIV co-infection.
This structure will provide steps to lead health care providers from increased knowledge, to building skills, to
receiving support to change practice that would fit newly learned skills and knowledge, to having access to
more advanced consultation in support of new practice, and, finally, technical assistance in system level
changes that may be needed.
As part of this effort, I-TECH will recruit, hire, train, and second to the BNTP MOH two dedicated Master
Trainers to train and mentor Botswana clinicians using the training package developed and piloted by I-
TECH in close collaboration with BNTP and BOTUSA. BNTP in collaboration with I-TECH Botswana
developed a TB Case management training plan for Botswana; Starting April 2008, BNTP with I-TECH
Botswana support plans to train 170 Nurses Officers, 80 Medical Officers and 40 Private doctors. The target
area includes all the districts in Botswana. Funds are requested to support the two positions (one nurse and
one doctor) to be seconded at MOH, to roll out the TB trainings in the districts of Botswana and to support
0.20 FTE I-TECH Botswana Training Coordinator who will oversee this process and the two Master
Trainers. A portion of these funds will cover technical assistance and management costs for I-TECH
08.T1104: Clinical Profile OF HIV Infection and ARV Treatment Outcome Among Children in Botswana
Expected cost and implementation period: This is a 1-year project to conduct analysis of routinely collected
pediatric data, with an estimated cost of $100,000
Local co-investigator: Drs. Jibril (MOH); Negussie Taffa; Stephane Bodika and Disasi Kisanga (BOTUSA)
Project description: Children age below 15 years made up 9.4% of the total 85,000 people on ART in
Botswana by May 2007. The ARV program (MASA) in Botswana is far advanced in terms of patient-based
information tracking system once an individual is put on ART. The system has limited some systematic
data on pediatric care and treatment that has not been sufficiently utilized to date. This project will conduct
initial data analysis on clinical and immunological profiles of children at HIV diagnosis, disease history, and
treatment outcomes including (if available from the routine record) treatment adherence, drug side effects,
toxicities and occurrence of opportunistic infections.
1)What are the clinical profiles HIV infected children who are initiated on ARV treatment?
2)How do these profiles differ by point of entry or referring program (PMTCT, out patient clinic and routine
3)What is the level of early mortality (at 3 and 6 months) and what are the common causes?
4)What types of drug toxicities are commonly observed early and late in the course treatment for children
put on ARV therapy?
5)What are the commonly observed opportunistic infections for children on ARV therapy and what factors
are associated with OIs?
6)What are chances of survival after 2-3 years on ARV therapy?
7)What is the level of loss to follow up and treatment adherence as defined by the country's treatment
Programmatic importance/anticipated outcomes:
Adequate knowledge of HIV manifestations, treatment outcomes and adherence issues among HIV infected
children in Botswana will inform quality care and treatment design and management. The analysis will be
used to describe the profiles of children in treatment, particularly with respect to adherence and retention,
and to develop a concept sheet for a prospective PHE to evaluate strategies to improve treatment
adherence among children who are suspected as ART failures due to adherence problems. Also part of
this initial project we will consult with other PEFPAR countries in the region who are implementing PHEs on
pediatric adherence in order to learn experiences. A third part of this initial project may be a sample record
review and abstraction from the paper-based medical records of the children receiving treatment at the 24
sites that are not linked to the electronic patient management system (IPMS). For this portion of the
evaluation, we will consult with those countries planning to conduct national pediatric outcomes evaluations
who have already developed protocols and data collection instruments that we might adapt for Botswana.
This is a retrospective record review of all children (below 12 years of age) initiated on ARV treatment
between 2003 and 2004 in six major ARV treatment hospitals in Botswana (Baylor, Nyangagbwe, Maun,
Molepolole, Selebe-Phikwe, Serowe/Palapye). These sites were among the few initial sites where pediatric
ARV treatment was started alongside the one for adults. It is believed that a complete treatment data worth
3-4 years (i.e. January 2003 to December 2007) is obtainable from the national HIV/AIDS data warehouse.
This data will be counter-checked with electronic patient records at each treatment site for completeness,
accuracy and consistency. Unique identifiers will be developed to merge data from the six sites since
children in Botswana do not have national identity numbers. Frequencies and cross-tabulations will
conducted on selected variables of interest to the study. As indicated above, the study does not involve
field data collection. Data extraction forms will be developed to address study objectives and variables.
Database managers at national HIV/AIDS data warehouse will move the information into data analysis
software of choice.
Population of interest:
Study population: All HIV infected children below 12 years of age who are on ART in public health facilities.
Information dissemination plan:
Study findings will be disseminated to health workers involved in care and treatment of children infected
with HIV in Botswana, and elsewhere as needed. Abstracts will be presented to the national and
international audiences for experience sharing.
Budget justification ($)
other (contractual services): 25,000
08.T1103: ITECH - Continuing Medical Education Courses
This activity continues to complement the Botswana national HIV/AIDS training program by providing
workshops on advanced topics of HIV/AIDS care and treatment. Two successful CME trainings on ARV
resistance and salvage ARV regimens, and neurological complications of HIV have been conducted. Each
session trained 75 public and private physicians.
In FY2008, I-TECH will provide another series of didactic and skill-building workshops to physicians on four
advanced HIV/AIDS topics selected by in-country clinicians. For each topic, an experienced clinician trainer
will conduct two workshops, one in Gaborone and one in Francistown. The 2008 scope of work includes
four, one-week trips to Botswana for the I-TECH expert clinical trainer. During each week of trainings, the
clinician/trainer will work with an in-country co-facilitator to conduct lectures, facilitate workshops, and
provide technical assistance to the in-country team as identified. The trainer will develop specific training
objectives prior to each training session, as the topic and audience are identified. PEPFAR funds will cover
time and travel, lodging and per diem of the I-TECH clinical trainer, training materials, training site logistical
costs, as well as a portion of overall I-TECH country management and administrative costs.
08.T1109: University of Pennsylvania
08.T1203: I-TECH - Laboratory Positions Support
Activity 1: Continuation of salary support for 1) Lab Scientist performing EID at Gaborone and 2) Lab
Scientist performing national quality assurance program
The International Training and Education Center on HIV (I-TECH) will be continuing with the salary support
for these 2 laboratory scientists. Costs include salary, benefits and local administration.
Laboratory Scientist placed at the Botswana-Harvard HIV Reference Laboratory
The laboratory scientist is responsible for testing infant DBS samples for early HIV diagnosis and the QA
system in the laboratory for infant DBS. The laboratory scientist also carries out CD4, viral load, and
resistance testing. The activities of this position are essential for the success of ARV treatment program in
Laboratory Scientist placed at the National Quality Assurance Laboratory
I-TECH will continue salary support for the position of one laboratory scientist at the National Quality
Assurance Laboratory (NQAL). This position characterizes proficiency testing specimens for different HIV
laboratory testing to support the NQAS; coordinates and organizes training in collaboration with the QA Unit
at MOH for lab techs; and assists laboratories in the annual proficiency testing. Shortage of staff at the
NQAL is an obstacle for quality assurance/quality control (QA/QC) implementation and rolling out of the QA
program in the country.
Activity 2: Continuation of Pre-Service Training Activities
Building upon the pre-service curriculum and training activities with the Institutes of Health Sciences (IHS) in
2007, and the technical assistance provided to explore development of the three-year program into a four-
year Laboratory Technician Bachelor's degree at the University of Botswana, I-TECH is requesting funds to
continue providing the TA to IHS and UB regarding the potential for a four-year degree program.
Activity 3: IHS capacity strengthening
In 2007 a pre-service training program was developed and PEPFAR supported the salary of five lecturers in
three district laboratories. Turnover is high and a steady cadre of trainers is not consistently available.
FY2008 funds will support three part-time trainers for these laboratories. It is anticipated that the part-time
employment may be more attractive to those with the qualifications and retention may be easier as a result.
08-X1418: I-Tech In-service Training Technical Assistance
(Change of funding mechanism from HHS/CDC New Coag (7853.08) to HHS/HRSA I-TECH (1331.08);
Change Prime Partner from TBD to Uni of Washington; Increase funding amount from 200,000 to 450,000)
08-X1418: In-service Training Technical Assistance
Since the beginning of the epidemic, the Government of Botswana has responded proactively and rapidly to
the HIV/AIDS epidemic by training health care professionals to provide HIV/AIDS prevention, treatment and
care services. In 2000, a training need assessment was conducted to inform the development of a
coordinated approach to in-service training. This laid the groundwork for the establishment of the KITSO
AIDS Training program, the national training program for HIV/AIDS care and treatment, in 2001. By
September 2006, 7,240 health care workers received theoretical and practical training in HIV/AIDS.
Despite the above-mentioned achievements, the following constraints were experienced: Roles for different
partners were not clearly stipulated; existence of many training materials and tools developed locally and
internationally targeting the same health care providers, and; absence of long-term training plan and
structure to ensure sustainability, comprehensiveness and responsiveness of the training programs.
To address these constraints, the Ministry, with USG funding, developed the KITSO Expansion Plan 2004
to guide the MOH and its training partners in the coordination of HIV/AIDS health professionals training in
Botswana. As recommended, the Department of HIV/AIDS Prevention and Care (DHAPC) established the
KITSO HIV/AIDS Training Coordinating Unit to ensure comprehensive, standardized, coordinated HIV/
AIDS training and bring all existing and future trainings under the leadership and direction of the MOH. To
further this objective, there is need to strengthen the current training system by developing training
structures and guidelines, evaluating and revising current training materials and developing new training
materials where necessary.
Conduct an assessment of existing HIV/AIDS training, training mechanisms, including the training models
(TOT, master trainers), coordination, monitoring and evaluation and the certification process; develop
appropriate structures and guidelines for the coordination, and effective implementation of in-service
08-X1420: Existing Program Evaluations
A number of PEPFAR-supported programs have been underway for several years now. Under this activity,
external process evaluations will be conducted on activities which have been supported for three or more
years and that are planned to continue in 2008. These activities include UMDNJ-FXBC Technical
Assistance to PMTCT, Pre-service Training and Health Worker Wellness; NASTAD Technical Assistance to
Community Planning; Community Capacity Enhancement Program), and; Task shifting to lay counselors.
Based on the scope of work provided, the selected prime partner will conduct site visits and interviews with
key informants and beneficiaries of the targeted partner activities in order to identify strengths and
weaknesses of the program, and in turn, help map the way forward. The focus of the evaluations will be on
the technical content and management of the activities, as well as the effectiveness of the interventions.
Best practices and program challenges will be documented and recommendations included.