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The National Antiretroviral Therapy Program (MASA) 2001-2011 TRANSLATING VISION INTO ACCESS

The National Antiretroviral Therapy Program (MASA) 2001-2011 TRANSLATING VISION INTO ACCESS. 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

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The National Antiretroviral Therapy Program (MASA) 2001-2011 TRANSLATING VISION INTO ACCESS

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  1. The National Antiretroviral Therapy Program(MASA) 2001-2011TRANSLATING VISION INTO ACCESS

  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. 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

  4. Health Spending in Botswana • Public health expenditure: 5% of GDP in 1999 7.2% of GDP in 2006

  5. Program Overview 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. Program Overview (2) • 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. Program Overview (3) • 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. Models used for scaling-up Public ART Delivery • 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. Achievements • 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 Jan 2002 – Mar 2011 TOTAL : 164,559 134250 (no data before 2006) 16554 15483 13755

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

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

  14. PMTCT Program Trend 2002-2010

  15. Double Orphans

  16. No. Of Home-Based Care Clients

  17. Challenges • 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

  18. Challenge (2)-CD4 350

  19. Way Forward • 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

  20. Way Forward (2) Response to emerging evidence • Test and Treat • Discordant Couples • Threshold for initiating HAART • UHAART and triple prophylaxis in pregnancy • Safe male circumcision

  21. Thank You THANK YOU T Keep TheThan Promise. Stop AIDS • All our partners for being there when we most needed you • PULA!

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