2. Size and Population Density of Botswana 2009 estimate: 1.99m 61% aged 15-64 1.9% growth rate 0.85% death rate 0.5% migration 62yrs life expectancy 60% urban 81% literate 81,730 sq km Texas/France

3.  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

4.  Public health expenditure: 5% of GDP in 1999 7.2% of GDP in 2006

5. 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

6. ◦ 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

7.  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

8.  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

9.  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

10. ARV site roll-out in Botswana: 2002 to date 32 ARV sites & 190 satellite clinics (89 dispense on site, 101 on outreach) ARV Sites

11. Patients on HAART Patients on HAART Jan 2002 – Mar 2011 Jan 2002 – Mar 2011 134250 13755 15483 16554 (no data before 2006) TOTAL : 164,559

12. Median CD4 Cell Count at Initiation Over Time MASA Integrated Dataset

13. Survival of Patients on HAART in Botswana Year of ARV initiation

16. PMTCT Program Trend 2002-2010

17. Double Orphans

19.  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

21.  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

22. Response to emerging evidence  Test and Treat  Discordant Couples  Threshold for initiating HAART  UHAART and triple prophylaxis in pregnancy  Safe male circumcision

23. THANK YOU T Keep TheThan Promise. Stop AIDS  All our partners for being there when we most needed you  PULA!