Following research undertaken by ACHAP, the University of Botswana, and Population Services International (PSI), on the usage, beliefs and attitudes of men and women on condom use, a program was developed in partnership with the Ministry of Health to scale up the promotion and distribution of free condoms throughout the country. With financial and technical support from ACHAP, millions of condoms have been procured to support this effort. These have been procured using the Ministry of Health procurement processes.

In addition, condom dispensers have been installed in traditional and non-traditional outlets in many parts of the country. District condom focal persons ensure these dispensers are consistently replenished. Districts have also been supported to develop and implement district specific condom education and promotion plans that have helped bring all partners in this effort together and agree on mechanisms for distribution.

Working together with the Ministries of Health, Local Government and other partners, ACHAP provided financial and technical support for the development of a comprehensive strategic framework for condom management through a consultative process led by Population Services International/Botswana (PSI/Botswana).

John Snow Inc (JSI) provided technical support to the process. This strategy was developed in recognition of the challenges faced with condom procurement, supply chain management (including forecasting, quantification, distribution and ware housing), marketing and demand creation, setting of targets and the monitoring of condom distribution in the country.

It built on the experiences of the national condom promotion programme as well as information from the 2007 condom programme evaluation supported by ACHAP. This national framework will assist in guiding the overall management of condoms in the country as well as the development and implementation of district-specific condom distribution plans and refocusing those already in place to enhance management and distribution of both free and socially marketed condoms at community level.

An innovative strategy to increase condom availability, accessibility and condom promotion was the establishment of a network of hair salons as sites for socially marketing female and male condoms. Female condom use has lagged behind male condom usage in the country. Capitalizing on the fact that women attending hair salons form a captive audience, salon owners and workers were trained as peer educators and condom distributors.

ACHAP through its partnership with PSI/B supported the training of 120 salon owners and their staff in HIV/AIDS prevention with emphasis on condom education, distribution and storage. These were from 81 salons in Gaborone, Palapye, Francistown and Maun. Some salon owners indicated willingness to distribute condoms at their salons and arrangements have been made for them to place orders from PSI. Additionally, 29 of PSI’s existing “merchandisers” have been trained to be able to provide weekly follow up with the salons that will be promoting, distributing and selling condoms.

In addition, 8 'Ambassadors' - well-known entertainers popular with youth – were recruited to join a program of pub-based condom promotions. Information Education Communication (IEC) support materials were designed to support this effort. Television and radio spots complemented by weekly radio call-in shows support the community and bar condom promotions as part of a major effort to increase condom availability and access. Print campaign materials are given to incentivize listeners to call in and share their experiences and opinions.

The Southern African region is undoubtedly the epicentre of the global HIV/AIDS epidemic. Epidemiological and biological evidence strongly suggest that conventional STIs increase the risk of individuals transmitting and acquiring HIV/AIDS. Thus efforts to limit the spread of the HIV/AIDS epidemic must include programmes aimed at preventing and controlling the spread of conventional STIs. During 2008, ACHAP provided both financial and technical support to the Ministry of Health to respond to the gaps identified in the national plan for scaling up HIV/AIDS prevention within the context of STIs.

National Strategy for strengthening STI partner tracing and management

With financial and technical support from ACHAP, the Ministry of Health recruited a consultant team from Makerere University Medical School and School of Public Health, Uganda to facilitate the development of a national STI partner tracing strategy. This would strengthen partner tracing and management with the aim of reducing, further, the incidence and prevalence of STIs in the country. The strategy was completed and it describes the current partner tracing situation in the country, analyses the current STI situation and provides an exhaustive three-year strategy and implementation plan.

Training health care service providers in STI management and control

By end of December 2008, 400 service providers from different districts and hospitals had been trained on various areas of STI management. This exceeded the 2008 set target of 300 health care providers to be trained. 238 were trained on the new STI management protocols while 69 were trained as TOTs on STI monitoring and evaluation and clinical mentoring. 93 private medical practitioners were trained on STI syndromic management and surveillance. This training is meant to provide standardised approaches to the management of STIs in the country within the context of a generalised HIV/AIDS epidemic.

Strengthening IEC/BCC for STI

ACHAP supported the production of IEC/BCC support materials for the STI programme particularly targeting clients at health facilities. A total of 160,000 copies of both English and Setswana brochures and flyers were printed and distributed. These included 40,000 brochures on Genital herpes, 40,000 of Genital warts, 40,000 on vaginal discharge and 40,000 on STI partner tracing. To support these materials, a series of radio talk shows were hosted addressing the topics included in the print materials. Twenty two radio talk shows were hosted on RB2 (Radio Botswana) over a period of twenty two weeks. The purpose of these talks was to provide opportunity for community members to ask questions and receive further information and clarifications on STIs and the specific topics covered in the print materials.

STI Monitoring and Evaluation

With support from ACHAP and WHO, the Ministry of Health started the microbiological survey of commonly occurring sexually transmitted infections during the third quarter of 2007. The objectives of the survey were:

• To determine the prevalence of STIs in 3 sub-populations: sexually active women attending family planning clinics, sexually active men/women undergoing general pre-tertiary health screening.
• To determine the aetiology of the 3 major STI syndromes of urethral discharge, vaginal discharge and genital ulcers.
• To determine the antimicrobial susceptibility patterns of N. gonorrhoea isolates from men with symptomatic urethral discharge.
• To determine the appropriateness or otherwise of the currently recommended syndromic treatment for urethral discharge in men and for other STI syndromes in which N. gonorrhoea is commonly implicated.

ACHAP procured reagents and drugs for this exercise as well as supporting the consultant working on this survey. This exercise was concluded in October 2008 and the final report is expected during the first quarter of 2009.

Youth in Botswana are one of the most important groups for targeted HIV/AIDS prevention interventions because they remain at high risk of getting infected with HIV/AIDS. Prevention of HIV/AIDS infection in this age group creates real prospects for long term control of the epidemic in the country. During 2008, ACHAP expanded its support for youth HIV/AIDS prevention programmes taking into account recommendations of the plan for scaling up HIV/AIDS prevention and those of the midterm review of the National Strategic Framework (NSF).

During 2008, ACHAP signed a memorandum of understanding with the Right to Play (RTP), an international humanitarian organization whose regional office is based in Uganda to expand the integration of HIV/AIDS prevention messages into sports and games under the ‘’Live Safe Play Safe (LSPS)” project for children and youth through specially designed sport and play programmes. A baseline survey was carried out in three areas (Gaborone, Kanye and Mochudi) to inform the development of the project implementation plan. Based on the implementation plan, LSPS trainers were trained from among partner NGOs to further train leaders in their respective catchment areas who will then be responsible for implementation of activities with in and out of school young people.

In support of school based peer education program, 12 Regional Peer Education Program coordinators were recruited and placed at 12 education centres of the Ministry of Education and Skills Development. The main function of these coordinators is to coordinate, direct and facilitate overall implementation of HIV/AIDS Programmes in schools in the regions where they are based. In order to strengthen the peer education programme in the country, ACHAP supported a study tour for ten (10) officers from the Ministry of Education to benchmark the design and implementation modalities of peer education programmes in two provinces of the Republic of South Africa (Gauteng and Kwa-Zulu Natal provinces). The lessons learnt during the tour helped shape the plans for implementation of the country peer education programme. ACHAP also supported the recruitment of a behaviour change communication specialist based at the Ministry of Education (MoE) headquarters to provide technical support to the expanded role of the MoE, HIV/AIDS prevention programmes.

Prevention of blood-borne HIV/AIDS transmission continues to be one of the key areas of the health sector HIV/AIDS response. The program supports technical capacity-building within the National Blood Transfusion Services to screen blood for all transfusion transmissible infections and builds the capacity of youth groups to mobilize more blood donors and develop targeted behavior change campaigns to prevent HIV/AIDS infection among those donating blood. ACHAP has supported the Ministry of Health by procuring laboratory equipment such as blood scales, blood donor chairs and cooler boxes to enable the blood transfusion service to expand the blood donor recruitment base and also meet the increased demand for blood donation created through the Pledge 25 youth prevention programme.

ACHAP provided financial and material support for the national launch of Pledge 25 as a national youth prevention strategy. This is an effort towards increasing the supply of HIV/AIDS negative blood in Botswana by encouraging more youth to become regular blood donors and remain HIV/AIDS negative. The youth in Botswana are the country's most strategically important group of blood donors because they account for about 60% of Botswana's blood donor population. To encourage the youth to donate blood, "Pledge 25" youth clubs are established to commit youths to remain HIV-negative through risk-reduction behaviors and donate blood at least 25 times. These clubs, which may eventually offer such rewards as scholarships and other educational benefits, will also encourage youth to continue to monitor their HIV/AIDS status and to be regular blood donors.

Prevention of Behaviour change communication remains an important and strategic input into the process of reducing the number of new HIV infections globally. The focus of BCC interventions has been the development of the necessary strategies and capacities to enable fully fledged programme implementation in subsequent years to address major gaps in this area in the country. The strategies developed are presented below.

Multimedia campaign on reduction of multiple concurrent sexual partnerships

One of the key drivers of the HIV epidemic in the country is having multiple concurrent sexual partnerships (MCP) by both men and women. A communication strategy to guide BCC interventions for the reduction of multiple concurrent partnerships was developed under the technical leadership of PSI and ACHAP with MOH and NACA as active members of the technical working group that developed the strategy. The national MCP campaign, branded “O icheke” - (meaning watch yourself) was launched in March 2009 and IEC materials to support this campaign were developed. Two priority target populations were identified as the focus of generalized media and community mobilization activities, based on the prevalence of MCP in these population segments and their susceptibility to behaviour change interventions. The first priority target population is young women aged 18-24 years who engage in MCP with wealthier, usually older, men to satisfy a range of material needs and wants, or advancement in education and employment.

The second priority target group is men aged 25-34 years having affairs with women other than their primary partners for sexual variety. There is widespread, often tacit, acceptance that men need more than one woman to satisfy them sexually, with myths such as ‘mistresses/concubines strengthen relationships’ and ‘man cannot live on bread alone’ supporting this norm. These relationships often have a compensatory function, providing benefits that are lacking in a main partnership or relief from stress or boredom.

A third key focus of the campaign, particularly in media commentary and community debate will be the phenomenon of older men having sex with young girls, particularly in rural areas. The two populations engaged in this type of cross-generational sex are distinct from 18-24 year old women engaged in MCP for personal or material gain and men 25-34 engaged in MCP for sexual variety in two key respects: firstly, there are much larger differences in age and wealth between the girls and men; and secondly the girls are too young and/or poor to enter into these partnerships of their own volition and feel pressured to do so by the older men involved.

Development of a communication strategy on male circumcision

In 2008, ACHAP supported the Ministry of Health to develop a short term communication strategy on safe male circumcision to provide information to the general public on this new HIV prevention strategy. This was done to allow the Ministry of Health and its partners to communicate well structured messages and create general awareness on this intervention while preparations were being made for a KAP (knowledge, attitudes and practices) study that would provide the necessary inputs to the development of a broader and longer term communication strategy for behaviour change.

With financial support from ACHAP, the Ministry of Health working together with PSI/B used the strategy to produce 85,000 English and 50,000 Setswana client brochures on male circumcision. As part of the overall support for the scale up of safe male circumcision in the country, ACHAP, on request from the Ministry of Health has recruited a public health specialist to support the ministry in the coordination of this new intervention.