MASA ARV Programme

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Introduction


Botswana was one of the first countries in Africa to establish a national antiretroviral therapy programme. “Masa,” a Setswana word meaning “a new dawn,” was the name given to the programme to signify the hope that ARVs offer to people living with HIV and AIDS to live longer, healthier lives by providing them with time to nurture their families and build a future for the nation. Prior to the introduction of ARV therapy in Botswana, the HIV/AIDS epidemic continued to spread unabated, characterized by high rates of morbidity and mortality–the ‘AIDS Kills’ message was, unfortunately, an accurate description of what was happening to Batswana– indeed, it seemed as if we were a nation without hope.


The Government of Botswana conducted a study in year 2000 to determine the macroeconomic impact of HIV/AIDS in the country (BIDPA, 2000).The study predicted devastating economic impact the epidemic would have on the lives of Batswana and the magnitude of human suffering AIDS would cause. These underpinned the decision in 2001 to provide ARV medication through the Botswana public healthcare system.


In order to assess the demand for ARV therapy, a joint task team comprised of officials from the Ministry of Health and experts from the international management consultancy firm, McKinsey & Company, was formed. The results of this rapid assessment—dubbed the McKinsey Report (2001)—formed the basis of the project description document for the ART programme.  It provided critical insights into priority areas and key modalities, as well as suggesting a blueprint for the provision of high quality, sustainable ART services in public health facilities.


Goal of the MASA ARV Programme


The overall goal of the MASA ARV programme is to enhance prevention efforts and reduce the impact of HIV/AIDS on the people of Botswana through the introduction and effective utilization of ARV therapy.


Operational modalities of the MASA ARV Programme


The MASA ARV programme team was constituted in September 2001. The objectives of the ARV programme were to:



  • Mobilize communities to support treatment and care of HIV infected individuals.

  • Build capacity, both human resource and infrastructure, necessary for the successful implementation of the programme.

  • Provide antiretroviral therapy (HAART) to eligible individuals.

  • Advise on and implement systems and policies to support the ARV therapy programme.

  • Guide/coordinate all efforts in the country geared towards implementation of the ARV programme.

  • Monitor and evaluate the programme to ensure continuous improvement of quality and effectiveness.

In addition, the team was tasked with implementation of the project description document across a number of technical areas:



  • Clinical Care: treatment protocols, guidelines and manuals, staff training.

  • Counselling: effective, participatory and confidential counselling services for HIV testing, ARV therapy and adherence.

  • Logistics – Pharmacy: procurement, storage and distribution of ARV drugs

  • Logistics – Laboratory: lab equipment, supplies, space and services.

  • Information Technology: appropriate and discrete storage and dissemination of information between different health service levels to support patient, pharmacy and laboratory management.

  • IEC: dissemination of information about ARV therapy and demand management.

  • Local Government Management and Infrastructure: preparation, implementation and evaluation of all aspects of the ARV therapy programme at the local authority level in the respective launch sites.

Rollout of the programme


The rollout model of the MASA ARV programme is built around a site model. A site is defined as a hospital and a number of clinics providing ART services at various levels. The activities of each site are coordinated by a Site Manager. The first phase of the rollout of the programme was completed in December 2004. This phase was characterized by an initial pilot stage involving four sites in 2002 followed by an expanded rollout to the rest of the 32 sites. The experience from the initial launch sites was used to project resource needs for subsequent sites.

After 2004, the second phase of the rollout was characterized by a number of strategies predominately designed to improve access to ART services including:



  • Clinic rollout: The focus is on improving access to treatment by devolving full ART service provision to all satellite clinics. As of December 2009, a total of 140 clinics are now offering ARV services throughout the country. Other programmes, such as MCH, PMTCT, TB and STI, can now seamlessly link to the MASA ARV programme.


  • Outsourcing of ART services: Services have been outsourced to the private sector to reduce congestion in the public health facilities and reduce delays associated with enrolling new patients into the treatment programme. As of May 2009, 12,565 patients were outsourced. This has effectively eliminated the waiting list with all patients eligible for HAART being initiated within two weeks.


  • Task-shifting .Nurse training on ARV prescribing and dispensing has increased access to ARV services in the public health sector.


  • Decentralisation of laboratory services: Initially there were 2 laboratories offering CD4 and Viral load testing in the country. Currently there are 23 laboratories performing CD4 testing 23 viral load testing, and 10 doing both facilities throughout the country thus reducing the turn-around times for results and improve the overall quality of care.


  • Treatment guideline improvements: These are continually being updated to keep current with the latest developments in HIV/AIDS treatment. Some of the recent changes include: ( click to see Guidelines)




    • Changing of first line regimen to reduce side effects, such as AZT induced anaemia.

    • Raising of the CD4 count from 250 to 350 cell/µl to enable early enrolment.

    • Making salvage therapy available, including integrase inhibitor.

Programme milestones



  • 2002/2003: ARV therapy was launched in four sites, making Botswana one of the first African countries to establish an ART programme.

  • 2003/2004: An additional seven sites were operational and by the end of the year, 11,500 patients were on ARV therapy.

  • 2004: The remaining 21 sites were launched. Thirty two sites enrolled 34,000 patients. Over the years, enrolment has significantly increased.

  • 2005: Launched Outsourcing of ARV Services (Public Private Partnership). Currently outsourced 13,622 patients

  • 2006: Clinic rollout of ART services launched. Currently there are 140 clinics providing ART services.                               

  • As of December 2011: 161,219 patients were enrolled on HAART of which 61.6% were females and 6.6% were children.

  • As of June 2012: 191,940 patients were receiving HAART in Botswana

Successes and impacts of the MASA ARV programme



  • Improved access to ART services:

    •  ARV services are currently being offered in 32 sites and 246 clinics across the country.

    • Out sourcing of ART services to Private Practitioners has fast tracked the enrolment of eligible patients and reduced congestion at government treatment centres.


  • Reduced morbidity associated with HIV and AIDS: A reduced number of clients in need of CHBC from 12,000 to less than 3,500 due to an effective of national ARV programme.

  • Increased survival Rate: The expansion of the HAART coverage has averted about 50,000 adult deaths through the end of 2007 and the five year survival rate of patients on HAART is 88.6 %, since the inception of the programme in Jan 2002. (HIV/AIDS in Botswana Estimated Trends and Implications based on Surveillance and Modelling, 2007).

  • Stabilization of the orphan population: This population has stabilized at about 50 000 for the past 4 years (currently 48000 orphans) mainly due to reduced mortality of parents.

  • Training: The government of Botswana in collaboration with development partners embarked on intensive and extensive training for health care providers in order to ensure effective and efficient implementation of the ARV programme.

Current Situation (June 2012)



  • By end of Septmber 2012, 198 553 patients were receiving HAART in Botswana:

- 167 503 patients were on treatment in the public sector, of which 62.6% were females.

- Children aged under 13 years accounted for 5% (8,383) of the public sector patients.

- A further 15 856 patients were treated by the private sector under the Government’s Out-sourcing Program.

- Another 15 194 patients were being treated in the private sector of the country by the Medical Aid Schemes and Work-place Programs.


  • This amounts to 97.9% of the projected 202 789 adults and children in need of ART at the end of September 2012). A cumulative total of 20 661 patients died while on HAART since the inception of the ARV program in 2002.

  • ARV services are currently being offered in 32 sites and 246 clinics across the country.

See 2012 Botswana National HIV & AIDS Treatment Guidelines.