Program Update: Accomplishments

The Botswana-Baylor Children's Clinical Center of Excellence was opened and officially dedicated by His Excellency Mr. Festus Mogae, President of the Republic of Botswana, on June 20, 2003. This new facility, the first of its kind on the African continent, provides state-of-the-art care and treatment to over 2,100 HIV-infected children and 260 families from Gaborone and across Botswana.

Camp Hope

With generous funding provided by AIDS Foundation Houston, in January, 2005 BIPAI sponsored camp experiences in the Mokolodi Nature Reserve for approximately 60 children who receive care at the Botswana-Baylor Children's Clinical Center of Excellence. Due to the huge success of this first camp, Camp Hope has become an annual experience, hosting approximately 60 children for a five-day overnight camp at the Maruapula private school. Camp Hope provides a setting for the children to enjoy a week away from home and the opportunity to realize that they are not the only children dealing with being HIV-infected. The children chosen for camp are chosen from our clinic population, with a strong preference for those kids who have had significant problems with medication adherence or stigma. The camp provides new perimeters for friendships among the children and strengthens the bond between them and the COE staff, many of whom volunteer their time to make this week a success. The children who have attended camp are often noticeably empowered by the experience. They have more confidence and they often take more ownership of their own medication adherence.

Teen Club

The Baylor Botswana Adolescent Clinic started in 2005 with 23 teenagers and, by June 2008, the clinic had enrolled over 275 teenagers. With antiretroviral therapy and expert clinical care, more of our children are surviving their early years and reaching adolescence. We estimate that by 2010 the COE will have over 600 teenagers. Teenagers need appropriate skills to help them in their transition to adulthood. In particular, teenagers in the COE need education on how to live positively with HIV and understand that there is life beyond HIV. They also require psychosocial support, particularly on how to deal with issues of stigma, relationships, life planning, and adherence. Teen Club is a recreational and psychosocial support intervention that evolved as a forum for teenagers to meet with other HIV-positive peers who are experiencing many of the same difficulties of adolescence. Teenagers who join the club know their HIV status and have the consent of their caregivers to attend club activities. Teen Club has experienced a huge growth trajectory since our first event in May of 2005 to over 85 attendees in July of 2008. The Teen Club events occur every month on a Saturday morning and a multidisciplinary team of adult healthcare workers regularly volunteer their time. Past events have included pool parties, nature reserve trips, drama skits, movie nights and sporting events. We also incorporate educational components into our Teen Club events including HIV/AIDS education, life skills, college and career planning, and goal-setting. To enable greater access to our activities, we reimburse them for transportation expenses and provide them all with a healthy lunch. In May 2008, the Teen Club members elected seven of their peers to serve as Teen Leaders. The Teen Leaders work with the adult volunteers to ensure successful planning of Teen Club activities.

KITSO Training

The KITSO training program was developed with technical assistance from several organizations working in partnership, including the contributions of Baylor College of Medicine personnel based in Botswana. This activity is made possible by support from PEPFAR through CDC/BOTUSA, UNICEF-Botswana, Ministry of Health and Ministry of Local Government. The KITSO training ensures comprehensive, standardized and coordinated HIV/AIDS training, and brings all HIV/AIDS-focused trainings under the direction of the Botswana Ministry of Health. Currently there are three different KITSO courses offered to healthcare workers: Basic KITSO which provides general HIV education, Pediatric KITSO which focuses on the needs of HIV-positive children, and Advanced KITSO which provides education on resistance mutations and other advanced topics to help treat patients who have failed standard antiretroviral regimens. Baylor Pediatric AIDS Corps doctors conduct all Pediatric KITSO trainings throughout the country, covering about 20 different sites per year. Each Pediatric KITSO session is a week-long course taught to approximately 50 health care workers, including nurses, medical officers, pharmacists, dieticians, and social workers.

Outreach

The Botswana-Baylor Children's Clinical Center of Excellence is currently involved with outreach projects in twenty-two communities outside of Gaborone. From the COE in Gaborone regular outreach visits are made to hospitals in Mochudi, Lobatse, Molepolole, Thamaga, Kanye, Goodhope, Phutadikobo (in Molepolole), Mabutsane, Ghanzi, Hukuntsi, Kasane, Maun, Tsabong and Gumare. The PAC doctor attached to Nyangabgwe Referral Hospital visits hospitals in Palapye, Mahalapye, Serowe, Selebi-Phikwe, Gumare, Gweta, Tutume and Masunga. Sites that are within 100km radius from Gaborone are visited twice a month whilst those further away are visited every 6-8 weeks. Since June 2008, our outreach Team has been expanded to include a nurse who accompanies a doctor to all sites. There is provision also to include a dietician, a clinical psychologist, a social worker, an M & E specialist and community outreach personnel on the visits when indicated. This expansion is meant to provide timely comprehensive support, training and mentorship to health care workers. To measure progress made in the program, the Outreach Team has developed a Site Follow-up Form which the doctors fill after each visit. This data is collected by the M&E Specialist in order to capture the outreach program's expansion and impact. As can be seen in the map below [to be sent later], our current national outreach coverage covers most regions of the country, with more focus on the heavily populated eastern sections. As reflected by flight paths on the map, our outreach visits to Maun, Kasane, Gumare, Ghanzi, Tsabong and Hukuntsi have been made possible by the excellent service provided by Airborne Lifeline, an organization which provides regularly scheduled flights to these remote sites, for the purpose of transporting ARVs, medical supplies, and much-needed specialists.

In-reach

Our in-reach program was established in 2007 as an intervention strategy for the most challenging patients in clinic who have difficult home situations and persistent inadequate adherence despite intensive adherence counseling. The in-reach team typically includes a nurse, a social worker, and sometimes a nutritionist who visit patients' homes to meet the family and assess the home environment. The goal is simple: to ensure that children and caregivers have all the support needed not only at clinic level but at family and community level. Currently, one hundred and fifty home visits have been completed. Working with caregivers in the relaxed familiar home environment encourages open expression of existing child and family needs. With such home visits, we have been able to help clients disclose to their families and thereby ensure that other family members are able to support caregivers. Education about medication is also done during the home visit, with an emphasis on adhering to ARVs as well as other components of the medical care plan such as keeping appointments and maintaining proper hygiene for the children. Family members are also encouraged to attend structured Adherence Counseling Sessions, which are conducted at the COE from Monday to Friday every week. To date, we have seen progress among the children and families we have visited, both at adherence level and general care.

Expert Patient Training and other Lay Person Training Programs

In partnership with the Clinton Foundation and the Ministry of Health, the doctors at the Baylor COE created a curriculum on HIV education to train expert patients, which are individuals infected with HIV who are doing very well on therapy and have been identified as role models in their communities. Expert patients receive a small stipend to assist other families to maintain good adherence on ARVs, to identify children who are in need of testing or treatment, and to ensure that these patients seek appropriate care. Thus they provide an invaluable link between the local health centers and their communities. The curriculum covers topics such as diagnosis and testing, clinical manifestations of HIV, disclosure to children, and the rights of families affected by HIV. The Expert Patient program is currently a pilot project providing training to expert patients, lay counselors, health educators, and nurses in 5 communities (3 in Southern Botswana and 2 in Northern Botswana). If the pilot project is successful, the program will be rolled out throughout the country in 2009.

A similar week-long training program has been created by Baylor staff to be used by BONEPWA (Botswana Network People Living With AIDS) to train recruited layperson staff for their Aunties / Uncles Program. The training, funded by Family Health International, covers various topics, including HIV basics, HIV medications and adherence, disclosure, stigma, basic child counseling techniques, recognizing symptoms of physical, mental and emotional problems and addressing all areas psychosocial needs in children and families. Baylor staff trained the trainers for BONEPWA and will act as a supporting team for the program within their agency.

BANA II Study

The Botswana-Baylor Children's Clinical Center of Excellence staff is currently conducting the BANA II study, the largest pediatric HIV/AIDS clinical trial on the African continent. The study is evaluating whether structured treatment interruptions can contribute to better long-term treatment outcomes in HIV-infected children. Enrollment of 600 children into the study was completed in July 2008 and analysis of the two study arms continues.

Improving the care and diagnostic strategies of Tuberculosis in children in Botswana

The COE plans to continue to upgrade the services for tuberculosis care for children in Botswana. The components of our plan include health worker education, enhancing our partnerships, mentorship, improved diagnostic capacity, and patient education. Baylor-Botswana is collaborating with the Botswana National Tuberculosis Program (BNTP) and Government of Botswana (GOB) to increase access to high-quality tuberculosis care and to train health care workers in the care of TB/HIV infected children according to the national guidelines. The COE will continue to assist hospitals in the country to improve TB screening and diagnosis of pulmonary TB in children. This will be achieved by adopting sputum induction for those children who are unable to produce sputum by coughing. A respiratory therapist will also train a group of health care workers who will then train health professionals across the country in the procedure. We are also advocating for the incorporation of sputum induction into the nursing curriculum in the Institute of Health Sciences around the country to equip our newly qualified nurses in the skill to perform a sputum induction. Ultimately, upgrading the country's ability to perform pediatric sputum induction will improve Botswana's diagnostic capacity.

The COE has also been tasked with designing and implementing an Information, Educational and Communication (IEC) strategy to target parents of children with HIV/TB disease, and adolescents at high risk of HIV and TB infection. The strategy will involve the creation of pamphlets and posters as educational tools for these target populations. The material will be available free of charge to patients in all of the out-patient clinics.

Affiliation with University of Botswana

In November, 2005, Baylor College of Medicine and the University of Botswana (UB) signed a memorandum of agreement for BCM to provide technical expertise and academic support as the University of Botswana builds its first medical school. The agreement was profiled in Baylor College of Medicine's Solutions Magazine. Read more