size and population density of botswana 2009 estimate: 1.99m 61% aged 15-64 1.9% growth rate 0.85%...
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The National Antiretroviral Therapy Program (MASA) 2001-
2011TRANSLATING VISION INTO
ACCESS
REPUBLIC OF BOTSWANA
Size and Population Density of Botswana
2009 estimate: 1.99m 61% aged 15-64 1.9% growth rate0.85% death rate 0.5% migration
62yrs life expectancy 60% urban 81% literate
81,730 sq km Texas/France
Botswana’s Health Care System Health care system is based on the Primary Heath Care
(PHC) approach. Decentralised health care delivery system, the District
Health Management Teams (DHMTs) responsible for implementation.
Greater than 90% of the population within a 15km radius from a health facility.
HIV prevention, treatment, care and support services are integrated within clinical care settings disaggregated at different levels according to complexity of the service.
Private sector provides 10% of health services, largely catering for their employees, dependants as well as the general public
Government provides health services/access at no cost to citizens
Public health expenditure: 5% of GDP in 1999 7.2% of GDP in 2006
Health Spending in Botswana
Botswana demonstrated a high level of commitment and political will to fight the HIV epidemic through instituting and funding programs toward HIV prevention & care
2001 Government commissioned McKinsey Consultancy & Co. to conduct a feasibility study on ARV therapy◦High mortality, High HIV infection rate-threat of
population extinction and reduced productivity
Program Overview
◦The program was to operate in line with the following work streams Clinical Care (nursing & medicine) Logistics (pharmacy & laboratory) Communication (IEC & Counseling) Information & Technology(patient level data) Monitoring & Evaluation and Research Training (KITSO) Health system strengthening (HR, infrast) Resource mobilization and partnerships
Program Overview (2)
The ARV program based on a site model approach for the following reasons:◦ Lack of previous experience and knowledge with HAART
◦ Concerns about creating widespread resistance
◦ Need to closely monitor and control numerous parameters in the early implementation phase
◦ Large initial cohort of critically ill patients either already in hospital or requiring hospitalization
◦ Hospitals had better latent capacity (staff, physical infrastructure and relevant skill mix)
Now being decentralized to PHC settings as a chronic disease
Program Overview (3)
Outsourcing of services to private sector - Act as a catalyst for implementation (16,554 pts outsourced March 2011)
Task shifting – nurses managing stable patients (ARV Nurse Prescriber & Dispenser )
Rolling out ARV initiation to 190 satellite Clinics, increased access to ART, target >600 clinics nationally
Models used for scaling-up Public ART Delivery
ARV Program evaluated 2009 Extending prescribing and dispensing to clinics Out-sourcing services as a catalyst for
implementation of ART program Task shifting scaled up ARV therapy services Number of patients receiving HAART increased
significantly, 94.3% eligible receiving therapy Intensive and extensive training of health care
providers- flagship ARV training program Established Monitoring and Evaluation
mechanisms including IT Periodic and timely review of clinical guidelines Routine HIV testing and counseling including
adherence counseling, ↑uptake, resistance Strong IEC and community mobilization and
involvement reducing stigma
Achievements
ARV site roll-out in Botswana: 2002 to date
0
5
10
15
20
25
30
35
Jan-02 Jul-02 Jan-03 Jul-03 Jan-04 Jul-04 Jan-05 Jul-05
Period
Nu
mb
er o
f A
RT
sit
es
32 ARV sites & 190 satellite clinics (89
dispense on site, 101 on outreach)
ARV Sites
Patients on HAART Jan 2002 – Mar 2011
134250
13755
15483
16554
(no data before 2006)
TOTAL : 164,559
Median CD4 Cell Count at Initiation Over Time
93106
122131 135 139
160
0
50
100
150
200
250
2002 2003 2004 2005 2006 2007 2008
MASA Integrated Dataset
75%
80%
85%
90%
95%
100%
0.5 1.5 2.5 3.5 4.5 5.5 6.5
Surv
ival
(%)
Time (years)
2002
2003
2004
2005
2006
2007
2008
2009
Survival of Patients on HAART in Botswana
Year of ARV
initiation
0
1
2
3
4
5
6
7
8
9
10
Inp
ati
en
t m
ort
ali
ty r
ate
(%
)
general hospitals primary hospitals
0
100,000
200,000
300,000
400,000
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000Total number infectedTotal need for ARTNew HIV infections
Nu
mb
er
infe
cted
/in
need
of
AR
T
Nu
mb
er
of
new
in
fect
ion
s/A
IDS
d
eath
s
PMTCT Program Trend 2002-2010
49%
67%
79%
83%
83% 81% 85%
91%98%
27%
37%
62%
83%
89% 89% 89% 94% 93%
3% 3%2%
2%0%
20%
40%
60%
80%
100%
2002 2003 2004 2005 2006 2007 2008 2009 2010
Pe
rce
nta
ge
Year
Women Tested Program Uptake HIV infected Babies
ARV Program started
Lay counselorsRevised obstetric Card & Registers
Revised PMTCT curriculumDBS-PCR
Routine HIV Testing became national policy
EID -DBS testing started in Oct 2006. Since then, more than 27,442 infants have been tested with results available
Testing rate calculated at delivery
Double Orphans
1995199619971998199920002001200220032004200520062007200820092010201120122013201420150
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
AIDS Non-AIDS Total
Nu
mb
er
of
Orp
ha
ns
No. Of Home-Based Care Clients
Inadequate human capacity Issues of medication adherence esp. in
children Emergence of drug resistance Inadequate mechanisms to measure quality
of care Inadequate testing of children and their
care In-adequate linkage and integration of TB,
PMTCT and other related program services at HIV service points.
Efficiency of the program Sustainability in ever changing environment
Challenges
2010 2011 2012 2013 20140
20
40
60
80
100
120
19 24 31 36 42
Total Annual Program Cost(Actual Cost to Government)
OTHERARV DRUGS
USD
in m
illio
ns
36%41%
42%43%
38%
53 63
76
87
99
Challenge (2)-CD4 350
Scale up task shifting (task sharing) initiative
Further strengthen M & E systems
Strengthen formation of Treatment Failure Teams and surveillance programs
Integration and improvement of linkages between key related programs (PMTCT, TB, STIs and MCH)
Intensify treatment and care of children and adolescents
Address sustainability by improving efficiencies, addressing quality and getting it right with prevention of HIV
Way Forward
Response to emerging evidence
Test and Treat Discordant Couples Threshold for initiating HAART UHAART and triple prophylaxis in pregnancy Safe male circumcision
Way Forward (2)
THANK YOU
T
Keep TheThan Promise. Stop AIDS
Thank You
All our partners for being there when we most needed you
PULA!
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