Prevention of HIV infection is top priority in Botswana’s national response. This is evidenced by a series of prevention interventions that Botswana has put in place and continues to strengthen. More than 90% of condoms are distributed by Central Medical Stores (CMS) while a few are donated by development partners.
A 2010 Condom Procurement Strategy has been developed to facilitate supply Chain management of condoms sourced from CMS to the primary and secondary consumers. Primary consumers are those facilities which procure directly from CMS for re-distribution such as Ministry of Health. The Secondary consumers supply to the end users such as Health facilities (Clinics and Health Posts). Currently all facilities including secondary consumers procure condoms directly from CMS. Feedback to CMS on condom stock outs and expiry is very minimal hence making it difficult for tracking condom availability, demand and targets. Implementation of condom strategy through supply chain management will assist in addressing these challenges.
Sexually transmitted infections
The link between HIV and other STIs might seem obvious. After all, the same sorts of risk behavior are involved. However, numerous studies seem to indicate that there is a stronger association between HIV and other STIs than would be expected simply from a behavioral link. Infection with STIs (including syphilis, gonorrhea and herpes) seems to increase the risk of both acquiring and transmitting HIV over and above a behavioral link.
Depending on the STI involved and the population, studies have reported that having an STI magnifies the risk of acquiring HIV by anything from two to eight times or more. In the case of people with HIV, having an STI increases viral loads both in the blood and genital secretions, thus making people more infectious – even when taking antiretroviral treatment. Therefore, reducing STIs in a population, or in the HIV-positive members of that population, could be a valuable additional way of reducing HIV infection.
This could involve:
Prevention of Mother- to- Child Transmission (PMTCT)
A total of 11,733 new Ante Natal (ANC) clients were registered during the October to December 2013 quarter. Of these, 20% already knew they were HIV positive. At delivery, of the 11,335 women who delivered, 3,125 i.e. 28%, were HIV positive. And of these HIV positive women at delivery, 3,058 were on treatment/prophylaxis during ANC, which translates to 97% uptake. In the January to March reporting period, a total of 11,681 new ANC clients were registered. 99% of New ANC attendees underwent an HIV test. 19% of them were already known to be HIV positive. At delivery, 10,719 delivered, of which 29% of women who delivered during the reporting period were HIV positive. Of the 2966 HIV (+) women who delivered and took treatment, 1%(23) were on ZDV, 61% (1908) were on HAART, 1%(47) also took both ZDV&NVP, while 988 (32%) were on TAP, giving an uptake of 95%. 67% of infants born to HIV (+) women were started on CTX. 19% of them were already known to be HIV positive.
Mother-to-child transmission; a process also usually referred to as vertical transmission is the transmission of HIV from an HIV-positive mother to her child during pregnancy, labour, delivery or breastfeeding. To curb this process, the PMTCT programme with the primary goal to prevent transmission of HIV to unborn babies from infected mothers was first nationally rolled out in Botswana in 2000 and by 2001 all public healthcare facilities were offering PMTCT services within SRH settings. HIV infected women identified under both Voluntary counseling and testing as well as routine HIV testing are advised to enroll in this program.
To ensure a comprehensive approach to PMTCT, the programme does not only focus on HIV infected women, but also on their partners and on parents- to- be whose HIV status is either unknown or negative. This comprehensive approach includes four elements, namely;
HIV positive women presenting at health facilities that provide triple ARV prophylaxis are initiated on ARV prophylaxis from 14 weeks of gestation (rather than 28 weeks). Any woman presenting for initial ANC or first diagnosed with HIV at 28 weeks of gestation or beyond is immediately started on AZT and is within two weeks screened for the need for life-long HAART initiation. Any woman who has a CD4 count of ≤ 350 requires HAART. For pregnant women who are not yet eligible for HAART, or are awaiting CD4 cell count results ARV prophylaxis is administered.
Orphan Care Program
This program was formed when mortality rate due HIV and AIDS was high and the numbers of orphans were increasing rapidly. The 2013 Spectrum estimated that there are 162,750 orphans in Botswana of which 108,210 are estimated to be AIDS orphans. This program however assists and talks of registered orphans.
The overall goal of the National Orphan Care Program is to improve quality of life of the orphans by ensuring optimal care and support through the provision of basic needs which are; provision of food and/or nutritional support, assistance to access to health care, education and shelter, assisting to access birth certificate and provision of legal aid and being able to access psychological and/ or emotional care. From the above mentioned basic needs it has come to light that some of the program deliverables are not easy to monitor and measure such as psychosocial support, hence only the provision of food baskets and school uniforms has been easier to report on.
In its effort to address the challenge, the department has found it worthwhile to work with non-government organizations that are based at the community level so as to be able to reach as many orphans as they possibly can. Regarding the performance of the program, this quarter all registered orphans were assisted with food basket. This includes even the Kweneng East (Molepolole) district which reported the highest number of orphans this quarter. The Orphan Program did not report for the October to December 2013 quarter and January-March 2014 Quarter.
Community Home Based Care (CHBC)
This program forms the cornerstone of Botswana’s efforts to relieve overcrowding at health facilities, which resulted from increased morbidity due to the HIV and AIDS epidemic. It also brings the community in as active partner into the national response to the epidemic, thus ensuring grassroots participation and meaningful contribution from variety of stakeholders. The program is co-hosted by MOH and MLG and it provides psychosocial and health care amenities to bedridden individuals at their respective homes. The program however only reports on the number of clients who were referred from MOH to MLG for psychosocial support and in particular food basket. This is a subset of the total number of CHBC clients receiving health care services at MOH. In an effort to address the reporting challenge two indicators have been developed to collect data on performance regarding provision of psychosocial support and health care services separately.
Since the introduction of the ART program, AIDS morbidity has gone down and hence more people graduate from the program. Statistics show a declining pattern in number of registered CHBC clients. During the quarter of October-December 2013, the number of registered CHBC clients stood at 1,187 compared to 1162 in January- December reporting period. For the same mentioned reporting periods, 98% and 99% of those registered were receiving food basket.
With the foregoing the NACA report recommends that given the progress made in strengthening SMC human capacity, more and intensive SMC demand creation campaigns especially in high volume areas needs to be conducted in order to make full utilization of the SMC teams on the ground.
Other recommendations are that STI education be intensified in urban areas, and that the community home based care program should be evaluated in order to establish degree of its relevance as far as HIV and AIDS is concerned. There is a need to establish if the home based care program still requires more funding from the HIV and AIDS budget. There is a need to explore sustainable means of funding Voluntary Counselling and Testing services and take testing to the people.