Washington D.C., USA, 22-27 July 2012 Partners in Innovation – Informing Botswana’s HIV/AIDS...

Washington D.C., USA, 22-27 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 ConferenceWashington DC, USA

23rd July 2012

Presented by: Themba L Moeti


Presentation outline

• Some key facts about Botswana

• ACHAP ; The Partnership

• Achievements, lessons learnt


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 15-49 years HIV+ (BAIS III 2008).•30.4% pregnant women aged 15-49 years HIV Positive.

•National HIV prevalence 17.6% (BAIS III 2008).•2011 HIV+ Population – 363,105 (Stover 2008).


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


A strategic Partnership: – Key HIV Challenges 2001

• 36.2% 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


ACHIEVEMENTS: Impact of Treatment Program 2002 - 2011

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)

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

-

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

200,000

Total patients on ART by year and need for ART

Adult Need for ARTReceiving ART

MOH Program data and NACA 2008* : HIV/AIDS in Botswana: Estimated Trends and Implications Based on Surveillance and Modeling


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

Nurses

& Nurse M

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Doctors

Pharm

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Social W

orkers

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Others

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%

AIDS Clinical Care Fundamentals Training Breakdown

Charles Hill Satellite Clinic 2008

tmoeti

can we confirm these latest figures as discussed.


Prevention Benefits of Improving Access to HIV Testing and Counseling

•MTCT rate reduced from > 30% to less than 4%

33

25

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2006

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2008

2009

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2011

2012

2013

2014

2015

MTCT rate

PMTCT Coverage

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 2004. •Positive advocacy for policy, test kit provision, (govt and NGOs) data management support, early infant diagnosis•Training & support lay counsellors for PMTCT


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 2009.• Collaboration with Safe Blood for Africa & MOH

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Blood Collected and HIV Trends (1997 - 2006

Blood collectedHIV Prevalelnce

• Blood donations increased 78%

• Discard rate due to TTI and HIV infection reduced from 11.8% 2003 to 2.5% 2010

tmoeti

can we review this Lesh - the pak increase was greater than 78%. is it possible to flag year 2003 on chart as year ACHAP supprot began


TB/HIV Co-Epidemics Trends in Botswana (1997-2008)

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20062008

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TB notification rates

HIV prevalence %TB incidence

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Support for Broader National HIV Response

• Development of the National Strategic Frameworks (2003-2009, and 2010 - 2016) (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


Scaling up effective prevention interventions: Safe Male circumcision

• Policy discussion & advocacy 2007• Decision to implement 2008• 2008: Collaboration with Futures Institute

on “Cost and impact of Male circumcision

in Botswana”• 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 42 000 SMC’s to date


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


Thank you for your attention

Acknowledgements:Government of BotswanaOther Development PartnersIn-country NGO implementing partnersBill & Melinda Gates FoundationMerck/The Merck Company Foundation

Washington D.C., USA, 22-27 July 2012 Partners in Innovation – Informing Botswana’s HIV/AIDS...

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