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!