1. Botswana National Program: Nurses Dispensing ARVs Tendani Gaolathe M.D Director Botswana-Harvard Partnership /PEPFAR Master Trainer Program

2. HEALTH INDICATORS HIV prevalence per health district, among pregnant women aged (15-49) years, Botswana, 2005 HIV prevalence among pregnant women aged 15- 49 years is 33.4%* HIV prevalence among pregnant women aged 15- 49 years is 33.4%* HIV is more prevalent among Botswana aged 25- 34 years HIV is more prevalent among Botswana aged 25- 34 years Infant mortality (per 1,000): 56 Infant mortality (per 1,000): 56 Maternal mortality (per 100, 000): 326 Maternal mortality (per 100, 000): 326 Under five mortality (per 1 000): 74 Under five mortality (per 1 000): 74 Life Expectancy at birth: 33.74 years Life Expectancy at birth: 33.74 years

3. Health Statistics-CSO 2003 Non-hospital sites Clinics 257 Clinics 257 Health Posts 336 Health Posts 336 Mobile Posts 761 Mobile Posts 761 Staffing (country-level): Nurses 26.1/10 000 Nurses 26.1/10 000 Doctors 3.1/10 000 Doctors 3.1/10 000 FWE* 5.2/10 000 FWE* 5.2/10 000 *family welfare educator

4. Patients on HAART in Botswana: July 2007 Total on HAART in Botswana – 90,478 Private Sector – 9,514 (approx.) 74,348 7,755 6,616

5. ARV site roll-out in Botswana 32 hospitals & over 100 satellite clinics Hospital Satellite Clinics ARV Site IDCC ARV Pharmacy ARV Laboratory

6. Clinic Rollout Plan 128 clinics to go to full prescribing and dispensing capability 128 clinics to go to full prescribing and dispensing capability 64 clinics upgraded to date, of which 64 clinics upgraded to date, of which 51 prescribing and dispensing 51 prescribing and dispensing 13 prescribing only 13 prescribing only 55 clinics to be upgraded by March 2008 55 clinics to be upgraded by March 2008 Challenge: adequate numbers of prescribers and dispensers Challenge: adequate numbers of prescribers and dispensers

7. Tsamaya Clinic

8. Pharmacy Renovation

9. Task Shifting 2006: after lengthy negotiations with MoH, Local Government and Nurses Association, agreement for nurse to Prescribe and Dispense ARVs 2006: after lengthy negotiations with MoH, Local Government and Nurses Association, agreement for nurse to Prescribe and Dispense ARVs Resulted in 2 nurse training initiatives Resulted in 2 nurse training initiatives -nurse prescriber* -nurse prescriber* -nurse dispenser -nurse dispenser Plans ongoing to integrate Plans ongoing to integrate Harvard/PEPFAR Master Trainer Program given mandate to train alongside MoH Harvard/PEPFAR Master Trainer Program given mandate to train alongside MoH Integrated into ongoing site support activities of Harvard/PEPFAR Integrated into ongoing site support activities of Harvard/PEPFAR *for continuing patients stable on ART (VL<400)

10. Traditional role of nurses at clinics and health posts Traditional role of nurses at clinics and health posts Backbone of Botswana Health Care System General patient consultation General patient consultation Prescribe (review) and dispense general medicines for both acute and chronic care purposes. Prescribe (review) and dispense general medicines for both acute and chronic care purposes. Manage medicines at the clinics and health posts: quantify, order, receive, distribute & maintain records. (Includes PMTCT medicines). Manage medicines at the clinics and health posts: quantify, order, receive, distribute & maintain records. (Includes PMTCT medicines).

11. Nursing roles in the HIV era Provide routine HIV Testing (task shifted to lay counselors) Provide routine HIV Testing (task shifted to lay counselors) Prepare patients for HAART initiation: Prepare patients for HAART initiation: - pre-HAART investigations - adherence counseling (ongoing task shifting) Patient follow up (defaulters ) Patient follow up (defaulters ) Collect ARVs on behalf of patients from the hospitals. Collect ARVs on behalf of patients from the hospitals.

12. Nurse prescriber training objectives To equip Nurses with the knowledge and skill: To equip Nurses with the knowledge and skill: -to correctly prescribe ARVs -to appropriately monitor therapeutic outcomes -To identify and manage appropriately adverse reactions related to ARVs -To address adherence issues -To understand when referral is needed (failure management, severe toxicity) -To provide other aspects of HIV care (lab monitoring, IPT, CTX)

13. Format nurse prescriber training Pre and post test Pre and post test 4 weeks training-1 week didactic, 3 weeks practical attachment 4 weeks training-1 week didactic, 3 weeks practical attachment presentations presentations group work/discussions group work/discussions role plays (including standard operating procedures) role plays (including standard operating procedures) Attachment to the hospitals or dispensing satellite clinics under supervision of Master Trainers Attachment to the hospitals or dispensing satellite clinics under supervision of Master Trainers Follow up of the participants at the sites by BHP-PEPFAR Master Trainers to monitor, support & mentor Follow up of the participants at the sites by BHP-PEPFAR Master Trainers to monitor, support & mentor

14. Goals of Nurse dispenser training To equip Nurses with the knowledge and skill: To equip Nurses with the knowledge and skill: -to correctly dispense ARVs -to appropriately monitor therapeutic outcomes -To identify and refer for adverse reactions related to ARVs -To measure adherence and address/refer adherence issues -To review CTX use -To familiarize them with the tools required for managing ARV drug inventory and reporting. Capacity to do basic inventory in absence of pharmacy staffCapacity to do basic inventory in absence of pharmacy staff

15. Format nurse dispenser training Pre and post test Pre and post test 4 days didactic training 4 days didactic training presentations presentations group work/discussions group work/discussions role plays (including standard operating procedures) role plays (including standard operating procedures) Attachment to the hospitals or dispensing satellite clinics under the supervision of a pharmaceutical officer Attachment to the hospitals or dispensing satellite clinics under the supervision of a pharmaceutical officer Follow up of the participants at the sites by BHP-PEPFAR Pharmacist Master Trainers to support, monitor & mentor them. Follow up of the participants at the sites by BHP-PEPFAR Pharmacist Master Trainers to support, monitor & mentor them.

16. Success of the training Plan was to train 120 Nurses on ARV drug management & dispensing in 2007: Plan was to train 120 Nurses on ARV drug management & dispensing in 2007: - 86 nurses trained on dispensing - 40 nurses trained on prescribing (20 currently in training) - 40 nurses trained on prescribing (20 currently in training) Most of trained dispensing nurses are assisting the pharmaceutical officers at 33 satellite clinics with ARV dispensing. Most of trained dispensing nurses are assisting the pharmaceutical officers at 33 satellite clinics with ARV dispensing. Most dispensing nurses are also active Most dispensing nurses are also active

17. Patients seen by 2 prescribing nurses IDCC- July-Sept 2007 MonthFemaleMale Sub Total July201189146123347312 August118928357201149 Septembe r 12141902921170 Total 1390(57 80) Very low % needed referral, appropriate regimens used

18. Mentoring and monitoring of quality at facilities Combined activity between sites and Master Trainers Combined activity between sites and Master Trainers Ensures that nurses get adequate mentoring Ensures that nurses get adequate mentoring Data collected will also be used for improvement and real-time monitoring and evaluation of program Data collected will also be used for improvement and real-time monitoring and evaluation of program Tools developed include: Tools developed include: activity log (Nurse to complete for each encounter)activity log (Nurse to complete for each encounter) Performance evaluationPerformance evaluation Chart reviewChart review

19. Activity log: Dispensing Date Patient file # Age Gende r (M/F) Last VL (date) Last CD4 count (date) Pregnancy status Y/N/ UNKNARegimenNewRefillSwitchRegimen Date started Date of next refill

20. Mentoring and monitoring of quality-proposed Nurse dispensing: Performance evaluation checklist (observed) Performance evaluation checklist (observed) Pharmacy logs Pharmacy logs Activity log (quality and minimum activity) Activity log (quality and minimum activity) Chart review Chart review Nurse prescriber Performance evaluation checklist (observed) Performance evaluation checklist (observed) Chart review Chart review Activity log (quality and minimum activity) Activity log (quality and minimum activity) Outcomes (VL suppression) Outcomes (VL suppression)

21. Challenges/way forward Workload Workload Minimum and maximumMinimum and maximum Re-deployment of nurses to other positions Re-deployment of nurses to other positions Mentoring needs to be strengthened Mentoring needs to be strengthened How to ensure this occurs at the district and local levelHow to ensure this occurs at the district and local level Continuous monitoring and evaluation essential to maintain quality of care, ARV service levels and adherence Continuous monitoring and evaluation essential to maintain quality of care, ARV service levels and adherence Focus on outcomes over time Focus on outcomes over time Integration of the prescribing and dispensing training Integration of the prescribing and dispensing training