Botswana Fiscal Year 2008 Country PEPFAR Operational Plan (COP)

BOTSWANA

Project Title: Botswana FY 2008 Country Operational Plan (COP)

Budget Summary:

	Field Programs Funding by Account						Total Funding
	Allocated as of February 2008			Allocated June 2008			Allocated as of June 2008
Implementing Agency	GAP	GHCS - State	Subtotal: Field Programs Funding	GAP	GHCS - State	Subtotal: Field Programs Funding	New Subtotal: Field Programs Funding	Subtotal: GHCS Central Programs	Grand Total:  Field & Central Funding
DOD	-	1,667,000	1,667,000	-	155,000	155,000	1,822,000	-	1,822,000
DOL	-	200,000	200,000	-	-	-	200,000	-	200,000
HHS	547,000	40,177,000	47,724,000	-	3,047,300	3,047,300	50,771,300	5,787,747	56,559,047
Peace Corps	-	1,450,000	1,450,000	-	-	-	1,450,000	-	1,450,000
State	-	3,246,000	3,246,000	-	6,121,000	6,121,000	9,367,000	400,000	9,767,000
USAID	-	23,271,000	23,271,000	-	(834,300)	(834,300)	22,436,700	925,000	23,361,700
TOTAL	7,547,000	70,011,000	77,558,000	-	8,489,000	8,489,000	86,047,000	7,112,747	93,159,747

HIV/AIDS Epidemic in Botswana:
Adults (aged 15-49) HIV Prevalence Rate: 24.1% (UNAIDS, 2006)
Estimated number of People Living with HIV: 270,000 (UNAIDS, 2006)
Estimated number of Orphans due to AIDS: 120,000 (UNAIDS, 2006)

Country Results and Projections to Achieve 2-7-10 Goals:

Botswana	Total # Individuals Receiving Care and Support	Total # Individuals Receiving ART
End of FY 2004*	52,800	32,900
End of FY 2005**	69,800	37,300
End of FY 2006***	149,300	67,500
End of FY 2007****	224,300	90,500
End of FY 2008*****	284,510	104,882
End of FY 2009*****	312,961	115,370

^* "Engendering Bold Leadership: The President’s Emergency Plan for AIDS Relief.” First Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U. S. Department of State, March 2005.
^** “Action Today, a Foundation for Tomorrow: The President’s Emergency Plan for AIDS Relief.” Second Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U. S. Department of State, February 2006.
^*** "The Power of Partnerships: The President’s Emergency Plan for AIDS Relief.” Third Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U.S. Department of State, February 2007.
^**** "The Power of Partnerships: The President's Emergency Plan for AIDS Relief." 2008 Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U.S. Department of State, January 2008.
^***** Projections from FY 2008 Country Operational Plan

Program Description/Country Context:

Botswana has the second highest HIV/AIDS prevalence in the world. According to recent UNAIDS estimates, 24.1 percent of adults aged 15 to 49 are HIV positive. The number of adults living with AIDS is approximately 270,000 and there are 14,000 children younger than 15 years infected with HIV. According to the Botswana 2006 HIV Sentinel Surveillance data, the HIV infection rate among pregnant women aged 15-49 years was 32.4 %. A 2004 national population based survey (BAIS II) confirmed high infection rates in women (29.4%) and men (20%) aged 15-49. There is also a growing problem of orphans and vulnerable children (OVC); UNAIDS estimates that 120,000 children have been orphaned due to HIV/AIDS. With so many young people infected or affected by the HIV/AIDS, the epidemic is not only a severe health crisis but also a threat to the future development and vitality of Botswana as a nation.

Fortunately, the Government of Botswana (GOB) has made impressive strides in combating HIV/AIDS. The U.S. President’s Emergency Plan in Botswana intends to strengthen and expand these advances and to engage civil society more effectively in HIV/AIDS efforts to achieve the 2-7-10 targets.

Prevention: $24,391,085 ($20,440,300 Field; $3,950,785 Central) (31.5% of prevention, care and treatment budget)

Prevention activities in Botswana include prevention of mother-to-child transmission of HIV (PMTCT), preventing sexual transmission through ABC programs, blood safety and injection safety for medical transmission prevention, and other prevention including programs to decrease alcohol abuse. All prevention activities attempt to link with treatment and care programs as much as possible.

Botswana’s PMTCT program is the most successful in Africa and provides at least one prophylactic antiretroviral drug for 94% of all of the HIV-infected pregnant women in the country, and 16% received ARV therapy. Based on an assessment conducted in 2007, increasing the number of eligible women receiving ARV therapy during pregnancy, through faster CD4 testing and expedited processes with ARV clinics, is the most significant remaining challenge in PMTCT drug delivery. HIV transmission to infants has been greatly reduced and it is estimated that less than 7% of infants of HIV-infected mothers are HIV-infected themselves. Support in FY 2008 will focus on improving health workers skills at the district level to manage comprehensively the complex issues of pediatric care, especially infant feeding, improving the linkages of PMTCT services to treatment for both mothers and their HIV-infected infants and children, and improving coordination. It will include supplies and training for early infant diagnosis of HIV, linkages with family planning, and studies on the impact of infant feeding practices and infant mortality and stillbirths.

In FY 2007, the PEPFAR program provided strong support for abstinence curricula in schools and a range of programs for youth such as edutainment activities. With FY 2008 funds, the USG will continue to provide support for these efforts, including scale up and monitoring of in-school Life Skills programs for youth and outreach activities of the nationwide, media-based behavior changes communications program, Makgabaneng. The majority of interventions will involve community outreach and work with community nongovernmental organizations (NGOs). In addition, three activities will focus strongly on men. A comprehensive activity will strengthen prevention in major HIV-related clinical and community services, building on efforts in FY 2007. Prevention with positives will be a priority.

In order to strengthen systems for blood collection, testing, storage and handling---as well as systems for safe injection---PEPFAR will continue to provide financial and technical support in FY 2008 to strengthen human capacity, and provide essential supplies, equipment, and facilities.

An assessment of prevention activities was carried out in 2007, and recommendations will be implemented in 2008 through programs to complement the GOB’s condom program by promotion in nontraditional condom outlets in rural, underserved areas, development of peer-led HIV prevention activities for persons engaged in high risk behaviors (PEHRBs) through civil society groups, and new programs of prevention with positives. Support for assessments of capacity to increase access to male circumcision (MC) will be conducted.

Principal Partners: Blossom, Botswana Defense Force (BDF), Botswana Network of People Living with HIV/AIDS (BONEPWA), Family Health International (FHI), Hope Worldwide, John Snow Incorporated, International Training and Education Center (I-TECH), PACT, Makgabeneng, Ministry of Health (MOH), Ministry of Education (MOE), Ministry of Labor and Home Affairs (MOLHA), Ministry of Local Government (MLG), the Supply Chain Management Systems Group (SCMS), Pathfinder International, Population Services International (PSI), Safe Blood for Africa, UNICEF, University of Medicine and Dentistry of New Jersey, and Youth Health Organization (YOHO).

Care: $27,019,000 ($26,644,000 Field; $375,000 Central) (34.9% of prevention, care and treatment budget)

Following assessments of palliative care activities conducted in FY 2007, funding in FY 2008 will go to support twinning activities to strengthen training in community and home based palliative care, strengthen community organizations and NGOs, and support a refugee program.

PEPFAR funds will be used to continue capacity building of health care providers on the co-morbidities of TB and HIV, with emphasis on training, quality assurance and supportive supervision. A new activity will target HIV-infected TB patients. Major challenges include the fact that Botswana lacks a current national medium-long term strategic plan for comprehensive TB, and has inadequate human resources.

In 2007, OVC activities included completion of the National Situation Analysis, development of OVC Guidelines, the Psycho-Social Support National Training manual and increasing support to 30,000 OVCs. In FY 2008 the program will identify additional programs that can go to scale with services including public-private partnerships, and working with NGOs, CBOs and FBOs. The Circles of Support program will be scaled up to ensure that OVC are all enrolled and retained in schools. A major challenge is that OVC implementers are generally small in size and reach.

Voluntary HIV/AIDS counseling and testing (VCT) is provided by a network of Tebelopele VCT centers, other NGOs and community based organizations, and government facilities. VCT services are available throughout Botswana. Adding mobile caravans and work place services helped VCT outreach to expand in 2007 and social marketing and community mobilization intensified to target more couples and men. The emerging challenge in 2008 is to meet the high demand created by these campaigns. In addition, post-test support and prevention services remain inadequate. The growing numbers of HIV infected clients who do not qualify for antiretroviral treatment (ART) need follow up and prevention services. Clear counseling and testing guidelines for children and adolescents are needed and improved provider-initiated testing.

Principal Partners: Academy of Educational Development (AED), American International Health Association, Botswana Christian AIDS Intervention Program, BDF, Catholic Relief Services, Hope Worldwide, Humana People-to-People, I-TECH, the Marang Childcare network, MOE, MOH, MLG, Nurses Association of Botswana, Project Concern International, Tebelopele, UPenn and UNICEF.

Treatment: $25,924,962 ($23,138,000 Field; $2,786,962 Central) (33.5% of prevention, care and treatment budget)

In 2007 PEPFAR funds supported antiretroviral (ARV) drugs including pediatric formulations, logistics and warehousing, and strengthening quality assurance and information systems. In FY 2008 PEPFAR funds will continue to support procurement of ARV drugs, strengthen the systems of supply, quality control, medicines registration, as well as inventory management systems through development of a more robust logistics management information system (LMIS) to track commodity flow. Staff training will continue to assure a more efficient distribution of ARVs and related commodities to local government clinics. Human resource capacity continues to be a major challenge. PEPFAR support in FY 2008 will continue expansion of pediatric patient care and training activities, increase facilities, and conduct public health evaluations.

Funding in FY 2007 helped strengthen the laboratory infrastructure in Botswana. In FY 2008 support will continue to help ensure that laboratories have increased space, improved techniques and quality assurance, well-maintained laboratory equipment, a continuous supply of reagents, and an improved standard of practice among laboratory staff. Assistance for supply chain management, which began in FY 2007, will be increased to help improve procurement of supplies and reagents. Support to Botswana Defense Force (BDF) military laboratory services will also be ongoing. Key challenges in FY 08 will include reducing stock outs of essential commodities and supplies by improved and less expensive procurements, reinforcing decentralization, and improving coordination.

Principal Partners: APHL, Associated Funds Administrators/Botswana, Baylor University, BDF, Harvard School of Public Health, I-TECH, MOH, MLG, SCMS, UNHCR

Other Costs: $15,824,700

PEPFAR is supporting development of M&E curricula, training materials, and providing staff for M&E thereby aiding the decentralizing of health information systems and strengthening their management and performance. In FY 2008 support will continue to allow tracking of ARV, to carryout the third AIDS impact survey, conduct new public health evaluations and targeted evaluations. The lack of a national health informatics strategy and limited human resources are challenges.

Staff shortages and capacity building needs remain top priorities in Botswana. In FY 2007, PEPFAR funded an assessment of the health workforce which resulted in a revised human resource plan and policy recommendations. In FY 2008, support will continue for positions directly hired by the government as project posts. Training of health workers will also receive support as well as an evaluation of lay counselor cadre. Civil society organizations will receive support for capacity building and AIDS in the workplace activities will increase.

Principal Partners: American International Health Alliance, Botswana Business Coalition on AIDS, Botswana Network for Ethics, Law and HIV/AIDS (BONELA), Institute of Development Management, MOH, MLG, NACA, National Alliance of State and Territorial AIDS Directors (NASTAD), and University of Medicine and Dentistry of New Jersey.

Management and staffing activities will ensure effective implementation of PEPFAR. In FY 2008, the USG will implement recommendations to re-structure and co-locate the PEPFAR team, as well as increasing the numbers of other USG agency staff in addition to those hired by CDC. Appropriate numbers of locally employed staff will be recruited to fill staffing needs. Key challenges in FY 2008 will include moving into a new PEPFAR campus, recruitment of new staff, improved communications and more efficient working relations.

Other Donors, Global Fund Activities, Coordinating Mechanisms

Because Botswana is a middle-income country, the GOB bears the largest burden of the cost of HIV/AIDS interventions. However, significant additional funds and assistance are provided by the African Comprehensive HIV/AIDS Partnership (ACHAP---funded by the Bill and Melinda Gates Foundation and the Merck Foundation), the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), and UN agencies. Bristol-Myers Squibb, the European Union, China, Cuba, Germany, Japan, Norway, Sweden, and the United Kingdom provide other support. The World Bank is currently developing a $70 million HIV/AIDS project which will be funded in FY 2008 through a low interest loan.

Coordination of support is done through the Development Partner Forum and the Global Fund Country Coordinating Mechanism, which both are chaired by the Ministry of Finance and Development Planning. Additional coordination occurs through the National AIDS Coordinating Agency (NACA)-chaired National HIV/AIDS Partnership Forum, and by various sector-specific groups at the technical level, working in NACA and coordinating across other Ministries.

Time Frame: FY 2008 – FY 2009

Approved Funding By Program Area: Botswana