1. KITSO AIDS Training Program Lecture 1: Introduction to the Botswana National ARV Program (MASA) delivered by Dr. Ndwapi Ndwapi, BHP

2. Learning Objectives Overview of the AIDS epidemic in Africa and Botswana. Understand the needs and challenges of the Botswana National ARV Program. Know the referral process and the eligibility criteria for initiating therapy within the Botswana National ARV program.

3. 1 NACA 2003 2 UNAIDS 3 President Mogae Introduction Botswana’s HIV prevalence is one of the highest in the world. 1 Up to 37.4% in certain age groups. 85 people are infected daily in Botswana. 2 One out of eight babies is born HIV positive. 66,000 children are orphans. ‘We are faced with extinction. People are dying in chillingly high numbers.’ 3

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7. Background In 1997, Vision 2016 established the goal of an ‘AIDS free generation.’ In 2000, cabinet declared AIDS a national emergency. In March 2001, MOH request to ACHAP for assistance in launching ARV therapy.

8. Background (2) An American consultancy developed a strategic plan pro bono, using a demand- supply model. Aug 2001, the resulting plan was accepted by Botswana Cabinet, Parliament, and House of Chiefs. Sept 2001, ARV therapy team was assembled by MOH.

10. MASA MASA (Setswana for ‘new dawn’) is the government’s national ARV therapy program. MASA’s aim is to provide HAART free of charge to all eligible citizens, non-citizen spouses of citizens, and their children. Brings renewed hope of longer, healthier lives for Batswana. It helps secure the future of the nation. MASA was the first national ARV program in Africa.

11. Needs Assessment In 2001 Botswana pop. 1.68 million. (48% male, 52% female) HIV positive, 300,000 –130,000 males (39,000 with CD4 <200) –150,000 females, (45,000 with CD4 <200) –16,600 with AIDS illnesses & CD4 >200 –10,000 children (7,000 >6 months old) Total needing HAART: 103,600 (110,000)

12. Demand Management Four Initial Sites : Gaborone, Francistown, Serowe, and Maun Eligibility Criteria: Presence of an AIDS-defining illness A CD4 count less than 200 cells/uL Any HIV+ child less than 12 months of age. Children over 1 year of age who are symptomatic or immunosuppressed.

13. Common AIDS-Defining Illnesses in Botswana Kaposi’s Sarcoma (KS) Crytococcal Meningitis Tuberculosis (TB) HIV Wasting Syndrome (BMI 10%) Pneumocystis Carinii Pneumonia (PCP) CMV Retinitis HIV Encephalopathy

14. Capacity Building Zero capacity assumed Six work streams 1. Recruitment & training of HCW 2. Laboratory capacity 3. Drug procurement, storage, and distribution 4. IEC for patients, family, and public 5. Procurement of space 6. IT Patient management system

15. MASA Launch Gaborone 2/1/02 Francistown 13/5/02 Serowe 13/5/02 Maun 20/7/02 Jwaneng 1/4/03 Orapa 1/5/03 Tutume 8/10/03 Molepolele 9/10/03 Mahalapye 13/10/03 Kanye 23/10/03

16. MASA Launch (2) Gantsi 5/9/04 Mochudi 6/9/04 Letlhakane 4/10/04 Gweta 6/10/04 Goodhope 12/10/04 Rakops 13/10/04 Mmadinare 9/11/04 Ramotswa 16/11/04 Palapye 30/11/04 Masunga 12/1/04 Hukuntsi 1/4/04 Lobatse 15/4/04 Bobonong 17/5/04 Kasane 15/6/04 Selebi-Phikwe 22/6/04 Gumare 25/6/04 Thamaga 19/8/04 Tsabong 30/8/04 Sefhare 2/9/04

17. Accessing Treatment through MASA 1.Counselling & Testing for HIV An important entry point for HIV prevention and care. Few people know their serostatus (stigma, confidentiality issues, fear). April 2000, Tebelopele Centres were launched. - Provide anonymous, free, rapid HIV testing with same day results. - Rapid tests are locally validated and are diagnostic for HIV infection. - 137,000 people tested by July 2004.

18. Accessing Treatment through MASA 2. CD 4 Testing Patients are referred for CD4 testing from Tebelopele centres and other health facilities. HAART eligibility: CD4 <200/uL or AIDS- defining illness. PCP prophylaxis and IPT can be commenced where appropriate. Referrals from private sector.

19. Accessing Treatment through MASA 3. HAART ARV treatment is provided free to eligible citizens, non-citizen spouses of citizens, and their children. Treatment is lifelong. Need > 95% adherence to avoid resistance. Close patient monitoring is essential. On-going counselling must be provided about adherence, drug side effects, diet, prevention of transmission, family planning, and PMTCT.

20. Standard Care Services for HIV/AIDS Home Based Care & Palliative Care Terminal & beyond PLWAPLWH Exposed Uninfected STI Services, Behaviour Change, IEC, Universal precautions….. VCT Psychosocial & Spiritual Support PLWH/A…. Care givers… Bereavement.. Orphans… IPT – OI’s and related illnessesPEP ARV PMTCT PCP PROPHYLAXIS Routine Testing

21. NRTIs NNRTIs PIs Nucleoside Reverse Non-Nucleoside Reverse Protease Inhibitors Transcriptase Inhibitors AZT (Zidovudine) EFV (Efavirenz) LPV/r (Kaletra) 3TC (Lamivudine) NVP (Nevirapine) NFV (Nelfinavir) d4T (Stavudine) SQV (Saquinavir) ddI (Didanosine) RTV (Ritonavir) (AZT+3TC) (Combivir) ARVs in the Botswana National Program Special Order: ABC (Abacavir)

22. Botswana Guidelines NRTIs NNRTIs PIs AZT+3TC EFV or NVP ddI + d4T NFV / LPV/r 2 recycled NRTIs* SQV / RTV * Depending on resistance assay and specialist consultation. 1 st Line 2 nd Line 3 rd Line (Combivir)

23. MASA Successes Strong political leadership and support. Well funded by government and development partners (ACHAP, BHP, BOTUSA, Baylor). >80% adherence comparable or better than Europe and North America. Good laboratory services, IT system, drug supply system, and training program.

24. Program Challenges Destigmatisation of HIV/AIDS. Stigma remains a barrier to testing and care. Human Resources. Shortage of staff before AIDS epidemic. High turnover. Loss of staff due to transfers, retirement, resignation, move to private sector, and death/ill health. Record Keeping. IT patient management can be problematic.

25. Program Challenges (2) Frustration with daily demands of providing care. Demand >> Supply. The health sector is struggling to cope with the long queues of patients and full wards.

26. Summary Stigma & discrimination continue to hinder AIDS care. 80,000 on HAART in Sub-Saharan Africa. Only 1% of HIV-infected Africans have access to HAART. Prevention remains very important. Treatment is far more expensive than prevention of transmission.