The Masa Program - Advanced HIV/AIDS Care

In January 2002, the Government of Botswana took the bold step of launching Africa's first national anti-retroviral (ARV) Program – “Masa”. Masa, a Setswana word meaning "new dawn," heralds the rising of a dawn over Botswana's struggle against the HIV/AIDS epidemic and promises Batswana the opportunity to live longer and healthier lives by giving people living with HIV/AIDS more time to nurture their families and to help build a better future for Botswana.

The National Plan

In 2001, the Government of Botswana decided to provide ARV therapy to its citizens free of cost after a feasibility study that was commissioned by ACHAP and conducted by Mckinsey and Co. The feasibility study culminated in a strategy document that detailed how the Ministry of Health could build the requisite capacity and scale up treatment. Additionally, GOB activated a national emergency fast track system to build capacity for launching and maintaining the national program as well as forming a dedicated ARV team to implement the program by adopting a phased approach.

The phased approach began by prioritizing four patient groups for the first wave of treatment, by using 19,000 patients (out of an estimated need of 110, 000 most in need of immediate care) as the target for building capacity in the first year, and by selecting four strategically-located sites (Gaborone, Francistown, Maun and Serowe) for rolling-out the therapy program. The implementation plan developed by the Masa ARV team also addressed the main areas requiring capacity/capability building. These areas included:

• Policy, planning, and project management.
• Information, Education, and Communication (IEC), and community mobilization.
• Training of healthcare professionals.
• Staff recruitment and retention.
• Drug logistics.
• Laboratory and testing logistics.
• Information technology for nationwide tracking and monitoring of patients, laboratory samples, and medication utilization.
• Procurement and upgrading of space.
• Monitoring, evaluation, and operational research.

A deliberate decision was taken to implement the Masa Program within the existing health delivery system instead of creating a parallel structure while at the same time fully recognizing the urgent need to build capacity within the system; the need to involve the civil society, especially with respect to counselling and adherence management was even more appreciated. Furthermore, it was recognized that the Masa Program would contribute to strengthening of health systems since certain expertise beneficial to the rest of the health system, which would otherwise not be available, was/were availed through the program especially given the fact that the program was implemented as an integral part of the existing health delivery structures.

As lessons were being learned from the program implementation experiences, other strategies were conceived and implemented to enhance the program and its benefit. In this regard, routine HIV/AIDS testing and outsourcing of ART services to the private sector are the two important examples of note. Because of these strategic and farsighted approach and innovations where people had to think outside the box more often than not, the Masa Program has been a huge success that has grown rapidly. The program has been fully rolled-out to 35 ARV sites across Botswana (each site has 2 to 4 satellite clinics associated with it).

Since its inception, ACHAP has supported the ART programme by providing sustained financial and technical assistance to the Government of Botswana for the design, launch, roll-out and decentralization of this successful national programme. ACHAP's support of the Masa Program has been very critical and extensive especially at the beginning where there was urgent need to fast-track implementation.

ACHAP has funded the feasibility study by Mckinsey and Company, recruitment and hiring of a Masa Operations Manager during the first three years, recruitment and hiring of HIV/AIDS Experts (preceptors) from all over the world during the first five years of the program, supported the roll-out of an IT-based patient management system, co-funded the recruitment and training of healthcare workers through the KITSO training programme, increased laboratory capacity, donated Merck ARV drugs, renovated and provided air-conditioners to drug storage space at Central Medical Stores, helped develop infrastructure at hospitals and clinics, and funded information, education, and communication activities for the Masa Program.

In addition, with the Ministry of Health and the Ministry of Local Government, ACHAP has constructed/renovated 35 Infectious disease care clinics and satellite clinics around the country that made the Masa Program a true national program. This support has increased coverage and access to quality HIV/AIDS treatment services for all eligible people and tremendous gains in access to treatment have been achieved over the past 8 years averting at least 50% of deaths of patients currently on ART due to HIV/AIDS and AIDS.

Masa Operations Managers

• Dr. Ernest Darkoh.
• Mr. Segolame Ramothwa.
• Dr. Ndwapi Ndwapi.

Rolling out the Masa ARV Program

• 2001 - Situational analysis by the Mckinsey & Co., Consultancy.
• 2002/2003 - ARV launched in 4 Sites: the 4 sites enrolled 3500 patients on therapy.
• 2003/2004 - Additional seven sites operational : the 11 sites enrolled 11, 500 patients on therapy.
• 2004/2005 - Remaining 22 sites launched :32 sites enrolled 38,492 patients on therapy.
• 2005/2006 - 32 sites enrolled 54, 969 patients on therapy.
• 2006/2007 - 32 sites enrolled 75, 082 patients on therapy.
• 2007/2008 - 35 sites enrolled 95, 051 patients on therapy.

Treatment Eligibility

HIV Positive with:

• CD4 cell count ≤ 200.
• And or presence of an AIDS-defining illness.
• Or a child under the age of 13 years.

Priority Groups

• Pregnant women and with CD4 < 200 and/or AIDS defining illnesses and qualifying partners who fulfilled the same criteria.
• All HIV infected children older than 6 months of age who are inpatient
• All HIV infected TB patients with CD4 < 200.
• All adult in-patients with CD4 < 200 and or AIDS defining illness

Kitso Program

ACHAP partnered with Harvard AIDS Institute and The Ministry of Health to develop curriculum on HIV/AIDS clinical care. The program – known as KITSO ‘knowledge’ - has provided critical training in HIV/AIDS care and ARV therapy to Botswana’s health care workers through classroom training. All KITSO-BHP training activities are in direct support of the national ARV program. Since the start of the program, it has cumulatively trained 6300 health care workers and 1500 lay personnel in various training modules as illustrated in the table below. One of the key achievements from ACHAP support to the KITSO training program continues to be the creation of human capacity to roll out the ARV program to clinics across the country. The ARV clinics have benefited from KITSO training as services provided also include dispensing of ARVs and devolution of responsibility to nurses to treat stabilized patients on ARV as well as do laboratory tests on site.

Course	Number in Participation
AIDS Clinical Care Fundamentals	466 participants
AIDS Clinical Care Fundamentals Refresher	733 participants
Introduction to AIDS Clinical Care	1532 participants
Introduction to HIV & Bio Safety	687 participants
Medication Adherence Counseling	683 participants
Advanced HIV/AIDS Care and Treatment	470 Participants

NB: Some participants have attended more than one module so there is some duplication.

Clinical Preceptorship Program

During the initial years of ARV programme implementation, a clinical Preceptorship program was developed where HIV/AIDS specialist doctors from the United States and Europe came to Botswana for a period of at least 3 months to provide hands on training to local medical staff. In addition to on-site training and supervision of treatment teams as new sites were rolled-out, the program produced improvements in clinical management.

Merck drug donations

In addition to the funds dedicated to the project, Merck Company Foundation/Merck & Co., Inc., also donates two antiretroviral medicines, STOCRIN (Efavirenz) and CRIXIVAN (Indinavir sulphate). In late 2008, Merck announced that it would provide a further two medicines INSENTRESS (Raltegravir) and ATRIPLA through ACHAP for the management of patients failing standard regimens in Masa using the Merck medicines programme. The two drugs were donated at the beginning of the year in addition to the first two.

Assessment and Upgrading of Laboratory Capacity

Laboratory equipment has been a vital component of the ARV programme. ACHAP helped to upgrade the quality and capacity of Botswana’s clinical laboratories, purchasing and installing equipment for CD4 cell count and viral load testing at the Botswana-Harvard AIDS Institute HIV Referral Laboratory in Gaborone and at health facilities around the country. This process has significantly contributed in decentralizing services from hospitals to health clinics within districts, especially those districts with high populations.

Twelve laboratory technicians were recruited and trained and placed in clinical laboratories throughout the country. Additional Laboratory equipment is being purchased for District Hospitals and training of additional laboratory staff is being undertaken to support efforts of decentralizing this work. This expansion of HIV testing has relieved the pressure put on the two referral hospitals and has improved the turnaround time of test results from up to 8 weeks down to 2 days.

In addition, ACHAP in collaboration with MOH monitored the performance of the equipment that was procured to improve laboratory capacity in various sites. By the end of 2008, the Ministry of Local Government and the Ministry of Health had conducted 259, 057 CD4 tests and 157, 918 viral load tests in the country as part of new patient enrolment and patient monitoring.