The overall goal of this cooperative agreement is to build human resource capacity to support prevention, care and treatment, strategic information and other HIV/AIDS programs in the Republic of Botswana. University Research Co., LLC (URC) works with the Ministry of Health (MOH) in: (a) assessing the effectiveness of various HIV/AIDS implementation strategies; (b) designing/recommending interventions for enhancing HIV/AIDS and TB programme impact; and (c) providing technical assistance for implementing specific technical strategies for HIV/AIDS and TB. URC works directly in six districts in Botswana, but supports sub-partners and MOH to work nationally. The primary target population is health care workers, and health facility clients and their immediate families. In FY 2012, URC will continue to work with the MOH to strengthen Routine HIV Testing (RHT). URC will also assist the Botswana National Tuberculosis Program (BNTP) to address drug resistance tuberculosis. URC will continue to work with government facilities and build the capacity of MOH staff at national and district level to take over activities lessening our support over time. URC will also provide sub-grantee support to three key partners: 1) The Nursing Association of Botswana (NAB) implements a program to promote the wellbeing of health care providers; 2) The Botswana Red Cross (BRC) will increase refugee access to antiretroviral therapy, and; 3) The University of Medicine and Dentistry of New Jersey will work with the MOH to integrate sexual and reproductive health into the prevention of mother-to-child transmission of HIV (PMTCT) program. Emphasis will be placed on ensuring accurate and timely reporting, support visits, adequate documentation and regular consultation with CDC, MOH and other partners.

The Caring for the Caregivers Project aims to promote and enhance the health and wellbeing of all health professionals and support staff. The Nurses Association of Botswana (NAB) has been working with health care providers throughout the country to promote the health and wellbeing of health care providers through personal and professional support to empower them in their role as health care providers.

The program has provided palliative care services, psychosocial support, and spiritual care and support to nurses and other health workers through health worker support groups. NAB has offered care and support to individual health care providers affected by HIV/AIDS and other diseases and health-related conditions and helped develop wellness centers for health care workers to address their health and related needs in a private and protected environment.

NAB proposes to continue to scale up the establishment of support groups in district hospitals in Botswana. In addition, NAB will work to strengthen the capacity of existing support groups. NAB will train additional facilitators for support groups and provide psycho-social support and spiritual care to individuals and groups of health workers.

NAB will also provide individual and group care and support to nurses and health care workers infected or affected by HIV/AIDS, other diseases, and health-related conditions. NAB will continue to play a critical role in advocating and lobbying for policies affecting service provision and working conditions of nurses and health workers.

NAB will strengthen the monitoring of its activities to assess the impact and effectiveness of the program. This will be done through regular support visits by the NAB coordinator and staff. Regular feedback meetings with key stakeholders will be held. All these initiatives will be dependent upon timely and accurate reporting of activities.

Through an agreement with the Botswana Red Cross Society (BRCS), URC will continue to provide care and support services to the refugees in the camp in Dukwi. Services will include treatment of opportunistic infections including TB, cervical cancer screening, provision of cotrimoxazole, malaria prevention and treatment, and a variety of other clinical services for persons infected with HIV. The recent hiring of a doctor and nurse will allow services to be provided on-site. In the past, patients were transported to Francistown for care.

Botswana has a TB incidence of 536/100,000, a smear slide positive incidence of 181/100,000 (2008), a TB case detection rate of 68% and a treatment success rate of 64.5%.

Multidrug resistant (MDR) and extensively drug resistant (XDR) TB remain a worrying concern. Botswana has a high estimated MDR TB burden (2.5% among all TB cases), a high HIV prevalence (17%) and a high annual TB default rate of (10% for drug sensitive TB).

In FY 2011 URC assisted the BNTP to establish current status of TB and MDR-TB in Botswana through a seconded MDR-TB advisor. URC worked in two districts supporting implementation of improved recording for drug resistant TB, implementation of BNTP TB infection control guidelines, and helped address cross border control of MDR/XDR-TB.

URC will continue to support the BNTP in four key activity areas to consolidate gains made in FY 2011. We propose to exclude one activity which is the cross border management of MDR-TB. This activity will be coordinated at a supranational level. To compensate URC will strengthen its work at the national level to improve the programmatic management of MDR-TB and also provide more in-depth district support.

Strengthening national and district level responses for preventing and controlling MDR/XDR TB: URC will work with the BNTP to strengthen the programmatic response to MDR and XDR-TB expanding our support from two to four districts, working with TB coordinators to ensure correct use of TB registers, provide mentorship, monitor implementation of directly observed therapy (DOT), infection control, assess intensive case finding and enhance linkages to HIV services.

URCs MDR-TB specialist at the national level will transfer skills and capacities in MDR-TB programmatic management to an understudy BNTP staff member to ensure sustainability in the long term.

URC also proposes in FY 2012 to support four quarterly meetings on the programmatic management of MDR-TB to help update health care providers on the correct implementation of MDR-TB treatment and improve the management of MDR/XDR TB.

Enhancing implementation of infection control policies and guidelines: URC will hold trainings for coordinators and health care providers to entrench the implementation of the national infection control policies and guidelines. These trainings will be complementary to the clinical training on management of MDR/XDR-TB. We propose to train 75 health care providers. URC will also continue it work in supporting infection control risk assessments and assist in developing facility infection control plans.

Strengthening surveillance of MDR/XDR-TB: URC will continue to support the BNTP to improve recording and surveillance for MDR-TB by ensuring that quarterly and annual reports for MDR-TB management are produced, together with other partners ensure ongoing mentoring and supervision at the 5 MDR-TB initiation sites. URC will also assist the BNTP revise and update the MDR-TB guidelines and registers. URC will continue to assist in the roll-out of the electronic open medical record system for multi-drug resistant TB. URC coordinate with the National TB Reference Laboratory to help assist in improving access to diagnostics for MDR-TB including Gene Xpert and culture.

Supporting advocacy, social mobilization and communication of MDR/XDR-TB: URC will continue to provide support in the development of materials and brochures to improve community linkages and response.

URC provides support to the MOH in strengthening uptake and quality of Provider-Initiated Testing and Counseling (PITC), referred to in Botswana as Routine HIV Testing (RHT). URC works with MOH to strengthen RHT through development of guidelines, training materials, job aids, training, improvement of data collection; strengthening supervision and management through mentoring. In FY 2012, URC will consolidate its activities in the five districts they currently cover. These are Kweneng East, Kweneng West, Good Hope, Charles Hill and Mahalapye. Funds will support activities geared towards addressing major challenges and gaps identified during the FY 2011 implementation period.

To address challenges related to Health Care Workers (HCW) poor implementation of RHT following training, COP 12 funds will support a prioritized in-facility training and mentoring model. This model will involve conducting on-the-job RHT trainings at high-volume health facilities. Post training follow-up, mentoring and support will be strengthened to increase testing yield by trained HCW. Cost-efficient training strategies will include using government conference facilities and institutions where the cost for accommodation and per diem are low. Careful selection of HWC for training will be done to ensure appropriate HCW are trained, to enhance performance following training. Other methods for selection, such as an application process and the piloting of District Trainers (DT) model, will be explored. To enhance sustainability, DT including previously trained HCW will be expected to take over RHT training activities in their respective districts. A minimum of 5 districts are targeted and two DT will be trained for each district. Initially, DT will train with URC trainers until they have developed skills to conduct trainings on their own.

URC will continue to work with RHT focal persons in the five districts, targeting five high volume facilities, and linking to the safe male circumcision programme in each district. Intensive bi-monthly mentorship support, use of facility based targets, facility improvement plans, observed practice and self-assessment checklists will be implemented. Lower volume facilities will be supported through regular contact phone calls, quarterly visits and attendance to a total of four quarterly district level experience sharing workshops bringing together all five districts.

In FY 2012, URC will work with district Monitoring and Evaluation (M&E) officers to distribute RHT registers, and improve data collection and reporting. Feedback to facilities on timeliness and correctness of reporting will be emphasized to facilitate the development and periodic reviews of facility based targets.

To further enhance sustainability of RHT at national, district and facility level, funds will support the documentation of project protocols, tools, systems, processes and lessons learned to ensure that project gains are maintained and replicated in other districts. These documents will be shared at monthly, quarterly and annual meetings with CDC and MOH.

The goal of the program (funded with $120,000 prior year pipeline) is to provide capacity development to the Ministry of Health's Department of HIV/AIDS Prevention and Care and Sexual and Reproductive Health Division for the integration of family planning services and HIV care and treatment. The François-Xavier Bagnoud Center (FXB) at the University of Medicine and Dentistry of New Jersey (UMDNJ) proposes to support CDC Headquarters (HQ) and CDC Botswana, to expand family planning and safer pregnancy education and support in HIV settings through the development of job aids and client information, education and communication (IEC) materials. These materials will be developed for the Botswana Ministry of Health as a generic package that can be adapted for use in other CDC partner countries.

A. Activity Description

The objective for this activity is to develop a set of comprehensive materials to support family planning service provision in HIV settings. These materials will facilitate counseling and provision of family planning methods, increasing overall uptake of family planning among HIV-infected women and men. They will also support the delivery of coordinated, consistent family planning messages throughout all settings where sexual and reproductive health services are provided or where they may be integrated into HIV services, including antenatal care, labor and delivery, post-partum care, HIV counseling and testing, and HIV care and treatment settings. The proposed project is based on preliminary in-country assessments conducted by CDC-HQ. FXB will work with the Botswana MOH, other in-country partners, and the MCH branch of the Division of Global HIV/AIDS, CDC-HQ to facilitate the following tasks.

Phase 1: Planning

FXB will conduct desk review to identify job aid and IEC materials needs; identify existing materials that are intended to facilitate counseling and provision of family planning methods in HIV settings in Botswana and other countries in Africa including posters and other audiovisual materials; attend two-day meeting at CDC-HQ to discuss findings of CDC SRH/HIV needs assessment; support additional needs assessment and in-country information gathering with CDC-Botswana and MOH; draft brief guidance memo for MOH regarding implementation, monitoring, and evaluation of the job aids and IEC materials.

Phase 2: Materials Development

This will include a review outline for job aids and IEC materials with CDC-HQ, CDC Botswana and MOH. This will be followed by development piloting and revision of materials after review by CDC and MOH Botswana.

Phase 3: Approvals and Launch (To be implemented by CDC Botswana and MOH)

MOH and CDC approvals for finalized materials will be obtained. MOH will convene sensitization and materials launch meetings for relevant stakeholders, departments, and District Health Management Teams.

The government of Botswana is hosting more than 3,400 recognized refugees in Botswana, most residing in Dukwi Refugee Camp within Dukwi Village along the Kasane-Maun highway in the Tutume sub-district, Central District. The refugee community includes individuals from over a dozen countries including Namibia, Angola, Zimbabwe, Democratic Republic of Congo, Burundi, Rwanda, Somalia, Sudan, Eritrea, Ethiopia, Kenya, Liberia, and Uganda.

No accurate figures exist for the HIV prevalence in the camp. However, the government does not provide antiretroviral therapy (ART) and prevention of mother-to-child transmission of HIV (PMTCT) for HIV-positive pregnant women. The Government of Botswana (GOB) has stipulated that GOB programs cannot provide ART and PMTCT services to refugees, although it will permit these services to be provided through donor agencies. The US Government through PEPFAR program has committed to providing these services to the refugee population.

In FY 2011, the Botswana Red Cross Society (BRCS) supported by the United Nations High Commissioner for Refugees (UHCHR) and URC provided ARV treatment and PMTCT to refugees at the Dukwi clinic. There are currently 214 refugees accessing ART at Dukwi. All consenting refugees who test HIV positive receive a complete panel of blood tests including CD4 tests, full blood counts, and kidney function and those that qualify clinically are eligible for antiretroviral therapy.

The BRCS will continue to partner with MOH and URC to provide ARV treatment services for refugees at Dukwi. Specifically the support through the URC grant will provide laboratory monitoring of CD4 counts and viral loads and allow for the quantification, procurement and prescription of ART for all refugees newly qualified to access or currently on ART.

BRCS will continue to provide staff support through a doctor, pharmacist and nurse who will assist the existing staff at the government-owned Dukwi clinic. URC will provide ongoing support to mentor staff at Dukwi, align procurement to US government guidelines, ensure quality implementation through MOH standards, and facilitate timely reporting.