Washington D.C., USA, July 2012www.aids2012.org Partners in Innovation – Informing Botswana’s HIV/AIDS Response: Successes and Lessons Learned by the ACHAP Public Private Development Partnership (PPP) ACHAP Symposium - International AIDS Conference Washington DC, USA 23 rd July 2012 Presented by:Themba L Moeti

Washington D.C., USA, July 2012www.aids2012.org Presentation outline Some key facts about Botswana ACHAP ; The Partnership Achievements, lessons learnt

Washington D.C., USA, July 2012www.aids2012.org Some key facts about Botswana Population – 2,038,228 (2011 Census) Life expectancy – 54.4 years (67 years before HIV/AIDS) Persons living below the Poverty Datum line 20.7% in 2009/10; previously 30.3% in 2002/3 (CSO, 2011). 25% population aged years HIV+ (BAIS III 2008). 30.4% pregnant women aged years HIV Positive. National HIV prevalence 17.6% (BAIS III 2008) HIV+ Population – 363,105 (Stover 2008).

Washington D.C., USA, July 2012www.aids2012.org African Comprehensive HIV/AIDS Partnerships (ACHAP) Public-private development partnership: Govt of Botswana, Bill & Melinda Gates Foundation and Merck/The Merck Company Foundation. Established 2001 – Country priorities inform strategic direction – Private sector resources leverage government efforts: greater impact, fill capacity or /resource gaps – ACHAP financial, technical, human resources, infrastructure, and logistical support – Catalyze interventions, innovative solutions to program challenges – Equal partnership: Govt strategy & policy guidance, in kind contribution – Consultative approach, agreed governance structure; mutually agreed priorities

Washington D.C., USA, July 2012www.aids2012.org A strategic Partnership: – Key HIV Challenges % of pregnant women aged 15–49 HIV+. No public sector treatment programme Access to less than 5% in need AIDS leading mortality cause: 4 fold increase over 10 yrs in adults Predicted decrease in economic growth; 24–38% by 2021 (BIDPA 2000) Profound impact on deaths among young people: access to treatment an urgent priority; major gap in response –major questions on operational feasibility, affordability, sustainability –external development assistance greatly reduced with middle income status Public private partnership important opportunity for national HIV/AIDS response and helping sustain development gains

Washington D.C., USA, July 2012www.aids2012.org ACHIEVEMENTS: Impact of Treatment Program By end 2011; Total of 178,684 patients on treatment (95% needing ART) Treatment available in every district; –32 main ART sites –212 satellite dispensing clinics Mortality – halved in 5 years; > 53,000 deaths averted 2002 – 2007* High treatment adherence > 90% Decentralisation of lab diagnostic and monitoring capacity: High treatment coverage contributing to reduction in HIV transmission (052) MOH Program data and NACA 2008* : HIV/AIDS in Botswana: Estimated Trends and Implications Based on Surveillance and Modeling

Washington D.C., USA, July 2012www.aids2012.org ARV Programme capacity development and health systems strengthening Training – (Partnership: ACHAP, BHP, MOH) Preceptorship & KITSO AIDS Training Program > 8000 health workers and >1600 lay personnel: private and public sector Training; now mainly by locally based personnel Infrastructure: 35 Infectious disease care clinics Human resource support > 250 HCW in various disciplines: doctors, nurses, lab, pharmacy, counsellors Treatment rolled out to 32 hospitals, catalysed roll out to > 200 primary care facilities, all districts > 75% of positions supported absorbed into govt establishment Charles Hill Satellite Clinic 2008

Washington D.C., USA, July 2012www.aids2012.org Prevention Benefits of Improving Access to HIV Testing and Counseling MTCT rate reduced from > 30% to less than 4% Estimate (%) of HIV+ women receiving ART for PMTCT Source: Botswana HIV Prevention Modes of Transmission Analysis: NACA 2010 Prior 2004, slow treatment & PMTCT uptake Issues; stigma, counselling capacity, Routine HIV testing policy discussion 2003, introduction Jan Positive advocacy for policy, test kit provision, (govt and NGOs) data management support, early infant diagnosis Training & support lay counsellors for PMTCT

Washington D.C., USA, July 2012www.aids2012.org Catalytic support for Blood Safety & Youth HIV Prevention High HIV prevalence - challenges meeting blood requirement. Support provided to national blood service 2003 – 2007 to improve safety of blood supply. Unique youth HIV prevention programme “Pledge 25” to Collaboration with Safe Blood for Africa & MOH Blood donations increased 78% Discard rate due to TTI and HIV infection reduced from 11.8% 2003 to 2.5% 2010

Washington D.C., USA, July 2012www.aids2012.org TB/HIV Co-Epidemics Trends in Botswana ( )

Washington D.C., USA, July 2012www.aids2012.org Support for Broader National HIV Response Development of the National Strategic Frameworks ( , and ) (NSF) HR support to address critical shortage of skilled staff; Prevention Support: –HIV testing and counseling capacity development & support –Support to NGOs working in prevention: HR, logistics, programming and infrastructure support –Safe Male Circumcision TB/HIV BCC capacity dev; MOH, NACA, BCC strategic plan support; Research, Monitoring and Evaluation Support

Washington D.C., USA, July 2012www.aids2012.org Scaling up effective prevention interventions: Safe Male circumcision Policy discussion & advocacy 2007 Decision to implement : Collaboration with Futures Institute on “Cost and impact of Male circumcision in Botswan a” Modelling predicted circumcising 80% of eligible men by 2012 could avert 70,000 new infections by 2025 at a cost of US$689 per HIV infection avert could avert 60,000 new infections with target year of 2015 Programme launched April 2009 *Bolinger et al; The cost and impact of male circumcision on HIV/AIDS in Botswana JIAS 2009 Support ACHAP, CDC/PEPFAR & implementing partners Approx SMC’s to date

Washington D.C., USA, July 2012www.aids2012.org Lessons Learnt SMC: a programme with great promise; challenging to implement demand creation, complex interplay socio-cultural challenges and opportunities Scale up in sparsely populated setting Each setting unique: challenges & solutions Key lessons learnt past two years On threshold of testing of promising SMC devices e.g. PrePex Treatment: major success of country response and partnership Saved a generation; averted impending development disaster Development significance appreciated – macro level to “man in the street” Important prevention investment Sustainability challenges Looking forward; innovating to optimise access: Point of Care CD4, Viral load testing, linkage to care and prevention programmes

Washington D.C., USA, July 2012www.aids2012.org Thank you for your attention Acknowledgements: Government of Botswana Other Development Partners In-country NGO implementing partners Bill & Melinda Gates Foundation Merck/The Merck Company Foundation