The Merck Company Foundation/Merck and the Bill & Melinda Gates Foundation established the African Comprehensive HIV/AIDS Partnerships (ACHAP) to support Botswana, a country disproportionately affected by HIV/AIDS.

ACHAP's comprehensive approach includes HIV/AIDS prevention, treatment, care and support, and impact mitigation. At its inception, The Merck Company Foundation and the Gates Foundation committed $106.5 million to the partnership, and Merck agreed to donate its antiretroviral (ARV) medicines—STOCRIN^® (efavirenz) and CRIXIVAN^® (indinavir sulfate)—to Botswana's national antiretroviral (ARV) treatment program for the partnership's duration. In November 2008, Merck expanded its donations to include ATRIPLA^® (efavirenz 600mg/emtricitabine 200mg, tenofovir disoproxil fumarate 300 mg) and ISENTRESS^® (raltegravir).

In 2010, The Merck Company Foundation committed an additional $30 million over five years (2010–2014) to support Phase II of ACHAP. This additional funding will enable ACHAP to build on its progress by:

• Supporting the scale-up of safe male circumcision among HIV negative males aged 15–29 years, to reach 27.2 percent (127, 000) of national target by 2014
• Positioning ACHAP as a successful country-led public-private partnership model now and in the future, through focused and sustained stakeholder relations and engagement
• Systematically transitioning the support of the antiretroviral (ART) treatment program to the government of Botswana and enabling the national program to sustain quality and maintain treatment coverage
• Strengthening the National TB Programme in order to improve access to and utilization of integrated TB and HIV services on a national scale by 2014
• Improving the generation, utilization and sharing of strategic information and knowledge from HIV/AIDS and TB programs in Botswana in order to inform and improve programs in Botswana and the region by 2014

During Phase II, ACHAP will work to continue to transition the programs to the government of Botswana and other local organizations and to initiate a comprehensive communications strategy to leverage the achievements and lessons learned.

The partners selected Botswana because it had one of the highest adult prevalence rates of HIV/AIDS in the world (see below), a viable existing healthcare infrastructure, and strong political will and commitment to address the challenges of HIV/AIDS.

From the beginning, Merck and the Gates Foundation sought to create a program that would leverage private-sector management expertise to resolve social and public health issues. They also hoped to create a model of care, which, if successful, could inform and encourage others in government, international organizations, foundations and the private sector working to address HIV/AIDS in other countries or regions.

Lessons Learned in Botswana

• A successful national response to HIV/AIDS requires sound, enabling policy to drive and guide the right course of action
• Local, national and international partners must integrate and align all efforts with the national blueprint
• Success depends on building local capacity and achieving buy-in at all levels
• It is possible to implement effective antiretroviral therapy, even in a resource-limited setting
• A sustainable solution must address both treatment and prevention
• ACHAP is considered an important model for addressing the African HIV epidemic, and lessons learned can be leveraged to inform positive action in other countries in the region
• Working collaboratively and in a complementary fashion with other development partners has enabled the expansion and strengthening of key programs

A Daunting Task

When ACHAP was established in 2000, more than one in four adults was infected with HIV in Botswana—then the highest HIV prevalence rate in the world. HIV prevalence exceeded 30 percent among men and women in the 25–40 age group. More than one-third of children born to HIV-positive women became infected with the disease. The number of AIDS orphans had quadrupled in five years. Fewer than 5 percent of those in need of antiretroviral (ARV) therapy were receiving it, and health facilities were overburdened: Patients who were HIV-infected and in need of care occupied about 60 percent of hospital beds. There was a severe shortage of health workers and physicians, particularly those trained in the area of HIV/AIDS. Life expectancy at birth had declined by 13 years, and between 1991 and 2003, morbidity had increased fourfold among 25- to 44-year-olds. At that rate, the total population of the country was expected to be reduced by 18 percent, while the gross domestic product was projected to decline 4.5 percent annually, resulting in an economy 30 percent smaller than it would have been without the impact of AIDS.

Looking Ahead

While much progress has been made in Botswana, particularly in the areas of treatment, expansion of HIV counseling and testing services, much still needs to be done as part of a comprehensive, sustainable and successful response to the AIDS pandemic in that country. It is becoming increasingly apparent that if Botswana is to get ahead of this epidemic, the focus must be on prevention. In addition, ACHAP recognizes the need to build greater capacity among local organizations, increasing the capacity of communities to utilize and provide HIV/AIDS services.

Therefore, priorities for ACHAP going forward will include the scaling-up of prevention efforts, addressing the needs of patients coinfected with TB, improving the cost effectiveness of the Masa antiretroviral treatment program, and strengthening the capacity of local organizations for a sustainable national response. The ultimate goal is for the efforts and programs ACHAP supports to become either self-sustaining or integrated into the efforts led by the government of Botswana.

The main partners in the African Comprehensive HIV/AIDS Partnerships (ACHAP) are Merck/The Merck Company Foundation, the Gates Foundation and the Government of Botswana, but ACHAP works with many different partners from the private sector and civil society.

Government

Within the government, ACHAP works closely with the National AIDS Coordinating Agency within the Office of the President; the Ministry of Health—particularly the Departments of HIV/AIDS Prevention and Care, and Public Health; and various other ministries. The Madikwe Forum—created to bring together ACHAP and senior officials from the Ministries of Health, Finance and Development Planning, Education and Skills Development, Home Affairs, Local Government, Youth Sport and Culture, the National AIDS Coordinating Agency and the Office of the President for regular consultation—helps to monitor progress of ACHAP programs, provide strategic and policy guidance and address issues that arise.

Local Communities

ACHAP works with local institutions, including district administrations, district health management teams and facilities, healthcare workers and other cadres supporting the national HIV response at the district and community levels. Local community leaders and civil society organizations are also critical to implementation.

Other Development Partners

From a multilateral perspective, ACHAP has worked with the United Nations Development Programme (UNDP), the United Nations Children's Fund (UNICEF), the United Nations Joint Programme on HIV/AIDS (UNAIDS), the World Health Organization (WHO), the United Nation's Population Fund (UNFPA), the World Bank, the European Commission and the Global Fund. On the bilateral side, ACHAP works with the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the U.S. Centers for Disease Control (CDC), and the U.S. Agency for International Development (USAID).

Academia

Academic institutions also play an important role in healthcare capacity building, most notably in developing critical ARV training and preceptorship programs for healthcare workers. Key among ACHAP's academic partners are the University of Botswana, Harvard University, the University of California Los Angeles (UCLA) and the University of Pennsylvania.

Nongovernmental Organizations

The local NGO community is very involved in the ACHAP partnership, including NGOs focused on youth prevention, and/or support for people living with HIV and AIDS, and HIV/AIDS service organizations.

Botswana has shown an exceptional response to AIDS at the highest levels, and its progress in treatment access is an example to the world. This energy must now inspire a dramatic scale-up of a comprehensive HIV-prevention program for a sustainable, long-term AIDS response.

Peter Piot
Former UNAIDS Executive Director

ACHAP launched in 2000 with four objectives:

• To improve accessibility to comprehensive HIV prevention, care and support
• To improve access to highly active antiretroviral therapy (HAART) in the public sector for all people living with HIV/AIDS
• To strengthen sustainable improvement in healthcare systems and mitigate the impact of the HIV/AIDS epidemic
• To support NACA in performing a thorough needs assessment in HIV/AIDS prevention and care in all districts in Botswana

In the first four years, the program was delivered through national initiatives, in line with the above objectives, and through an invitation of proposals from a variety of organizations, including tertiary institutions, and research and civil society organizations, in line with the program goals. In 2005, a strategic plan was developed with the following six strategic objectives:

• To scale up the quality of—and access to—comprehensive HIV prevention services
• To expand HIV counseling and testing capacity
• To increase coverage of quality HIV/AIDS treatment services to all eligible people
• To increase the capacity of communities to utilize and provide HIV/AIDS services
• To improve ACHAP's institutional capacity to deliver effectively on its strategic objectives
• To strengthen partnerships and build capacity to support the sustainability of the national response

In 2007, ACHAP expanded its support to target coinfection of HIV and tuberculosis (TB). HIV infection has fueled an explosive increase in TB cases in Botswana since the early 1990s. In fact, it is estimated that 65–85 percent of TB patients are HIV-positive, and HIV-related TB is the leading cause of death among adult AIDS patients.

One of the strengths of ACHAP has been its full integration with government strategy, as well as its ability to harness private-sector expertise in support of national efforts to address HIV/AIDS. All ACHAP programs are developed through extensive consultation with all relevant government ministries. Partnership programs must build local capacity, demonstrate a measurable impact on the epidemic, be cost-effective, be appropriate to the setting in which they are delivered, and be sustainable beyond the life of the partnership. All programs were required to fit within the strategic goals of the Government of Botswana's National Strategic Frameworks for HIV/AIDS.

The African Comprehensive HIV/AIDS Partnership (ACHAP) demonstrates how public-private partnerships can make a meaningful and lasting contribution to a major public health challenge, helping to restore hope and transform the morale and prospects of an entire nation.

ACHAP has made a significant contribution to Botswana's response to the HIV and AIDS epidemic and has served as a catalyst for providing urgently needed infrastructure, equipment, human resources, training and program support for the Botswana ARV program.

Major achievements of the program:

• Halved the mortality rate in adults, saving over 50,000 lives between 2002 and 2007
• Dramatically reduced mother-to-child transmission and reduced new infections among children by at least 80 percent
• Contributed to significant improvements in blood supply safety.
• As of January 2012, 150,237 patients were on treatment in the public sector, of which 62 percent were females. Children aged under 13 years accounted for 5.6 percent (8,357) of the public sector patients. A further 16,181 patients were treated by the private sector under the government’s Outsourcing Program.
• Another 14,569 patients were being treated in the private sector of the country, by the Medical Aid Schemes and Workplace Programs. This gives a total of 180,987 patients currently receiving HAART in Botswana, which amounts to 96.5 percent of the projected 187,484 adults and children in need of ART at the end of January 2012. There were 1,587 new clients started on HAART in the public sector in January 2012, of which 76 percent were treated in clinics. A cumulative total of 19,560 patients died while on HAART since the inception of the ARV program in 2002.
• Developed sustainable treatment by supporting the recruitment of over 200 positions, on civil service terms, to help staff the treatment program and its rollout to the clinics over the project period. Through successful absorption of these staff positions into the government establishment, and with ongoing training of new staff, patient access to treatment is now available in over 200 clinics countrywide.
• Supported the development of the first National Strategic Framework for HIV and AIDS (2003–2009) and the second National Strategic Framework (2010–2016)
• Increased laboratory capacity so that more than 130,000 patients could be supported in their treatment in the public sector through a decentralized diagnostic and monitoring capacity that increased from an initial two referral centers to 14 district and primary hospitals. This enabled the system to cope with up to 20,000 new patients per year.
• Supported the introduction of routine HIV counseling and testing as part of normal medical care.
• Provided, in collaboration with Harvard University and the Botswana Ministry of Health, training for more than 7,600 of Botswana's healthcare workers in eight core modules on HIV and AIDS clinical care, largely with in-country faculty. This effort expanded on an earlier effort in which more than 3,200 physicians, nurses and other healthcare professionals received hands-on, clinic-based training from international HIV and AIDS experts through the partnership's preceptorship program between 2002 and 2006.
• ACHAP is currently transitioning its treatment program support to the Government of Botswana, a process reflecting the manner in which this program has matured over the past decade

ACHAP has also made significant contributions in the area of HIV prevention, including the development of a national plan for scaling up prevention, as well as improving condom availability and safe blood transfusions. However, ACHAP has not had the same impact in helping to drive prevention during the first phase of the program as effectively as it did treatment. Interventions need to be rapidly scaled up to slow the spread of HIV infection and meet the ambitious national goal of "zero new infections by 2016."