EDUCATION & TRAINING: KITSO

KITSO training participants and facilitators during and AIDS Clinical Care Fundamentals training in December 2009. Over 7,000 people have taken this course since 2001.

Mission

Background

Capacity Building

Curriculum & Implementation

Reference Corners & Resource Materials

Collaborations

Accomplishments

Monitoring & Evaluation

(Download a pdf of the January 2010 KITSO Update.)

Mission
The KITSO AIDS Training Program provides quality, multi-disciplinary, sustainable and standardized training in HIV and AIDS care, crafted specifically for Botswana's health professionals. KITSO is a collaboration of the Botswana Ministry of Health and the Botswana–Harvard Partnership for HIV Research and Education, made possible through support from the African Comprehensive HIV/AIDS Partnerships (ACHAP).

The name of this program was designed to incorporate the culture of Botswana and to capture the groundbreaking nature of this collaborative educational effort. While English is the official language of Botswana, the national language of Setswana is an important element of the country's proud heritage. "Kitso" is the Setswana word for "knowledge." KITSO AIDS also stands for "Knowledge, Innovation, and Training Shall Overcome AIDS."

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Background
In the face of the growing HIV threat—identified by then President Festus Mogae as a national crisis—in 2001, the Government of Botswana announced that it would provide antiretroviral (ARV) therapy free-of-charge to qualifying patients. This initiative, at the time without precedent in Africa, posed significant challenges to Botswana's already overburdened public healthcare system, especially in terms of personnel, infrastructure, and training.

Conceptualized through private seed funding, the KITSO AIDS Training Program was established in 2001. It is the Botswana Ministry of Health's national training program for HIV/AIDS treatment and care. KITSO was initially conceived, developed, and implemented through a collaboration between the MOH and the Botswana–Harvard Partnership (BHP).

In order to offer more training opportunities for healthcare professionals in Botswana, the KITSO AIDS Training Program was expanded in 2004 to include the expertise of additional partner organizations. Within this enlarged framework, BHP's KITSO Program (KITSO-BHP) continues to provide high quality, multi-disciplinary, sustainable, and standardized training to help healthcare workers understand and apply the Botswana national HIV/AIDS care and treatment guidelines.

KITSO-BHP's training efforts are made possible through the financial support of the African Comprehensive HIV/AIDS Partnerships (ACHAP), a collaboration between the Government of Botswana, the Bill & Melinda Gates Foundation, and The Merck Company Foundation/Merck & Co., Inc.

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Capacity-Building
Since its inception, KITSO-BHP has worked under the leadership of the MOH to increase local staff capacity within the healthcare sector and ensure the sustainability of HIV/AIDS care and treatment.

When ARV therapy was first introduced in Botswana in 2002, few physicians in the country had experience in AIDS treatment. Through KITSO training and front-line experience in the ARV clinics, healthcare professionals in Botswana have gained the expertise and confidence to both provide ARV therapy and train other healthcare workers at their treatment sites. KITSO-trained staff now provide ARV therapy at 33 hospital sites and 137 satellite clinics throughout the country, and currently serve over 130,000 patients enrolled in the national ARV program.

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Curriculum and Implementation
KITSO-BHP has developed a module-based training curriculum which is tailored to the Botswana National HIV/ AIDS Treatment Guidelines. The curriculum has been collaboratively developed and is regularly updated by national and international experts to ensure that healthcare professionals gain competency and confidence in the latest national standards of HIV/AIDS care and treatment.

Curriculum development and course implementation have been driven by the immediate need to train Botswana's healthcare workers in HIV/AIDS care in formats that provide a comprehensive grounding in good clinical practice without requiring long periods of staff release for training.

As mandated by the MOH, KITSO training modules are the national standard of training for HIV/AIDS care and treatment in both public and private sectors. The KITSO-BHP team oversees the standardized training implementation, curriculum development, updating, course examination and certification.

AIDS Clinical Care Fundamentals
Since its first offering in July 2001, AIDS Clinical Care Fundamentals has served as a gateway course to prepare Botswana's healthcare professionals to provide basic ARV therapy and other HIV/AIDS care. Training is carried out using either a facility-based or centralized format, depending upon the staffing needs of individual healthcare facilities. Between July 2001 and December 2009, 7078 healthcare workers completed this module. Following four days of lectures and case study discussions, the course concludes with a final examination. Participants who meet course requirements as determined by the MOH receive a certificate of successful completion.

The ACCF module has been packaged onto a CD-Rom for distance learning.

Since 2006 KITSO-BHP has been implementing distance learning as an alternative training format utilizing an audio-enhanced CD ROM of AIDS Clinical Care Fundamentals. Distance learning participants receive a training package, including the CD Rom, course binder and support materials for their self studies. A one-day classroom training activity where clinical scenarios pertaining to the learning objectives of the course are discussed. A final assessment concludes the distance learning experience.

Topics covered in AIDS Clinical Care Fundamentals:
1. Introduction to the Botswana National ARV Program
2. HIV Epidemiology and Pathophysiology
3. Laboratory Diagnostics in HIV/AIDS Care
4. Principles of ARV Therapy in the Botswana National Programme
5. Pediatric-and Adolescent-Specific Issues in HIV/AIDS Care
6. Pediatric-and Adolescent-Specific Issues in HIV/AIDS Psychosocial Care
7. ARV Drug Side Effects and Toxicities
8. Drug-Drug Interactions in ARV Therapy
9. Treatment Failure and Its Management
10. Adherence in ARV Therapy
11. Adult and Pediatric Opportunistic Infections and Other Complications in HIV Disease
12. Mother-to-Child Transmission and Its Prevention
13. Post-Exposure Prophylaxis (PEP)
14. TB and HIV Co-Infection
15. Summary of the Major Changes in the 2008 Guidelines.

AIDS Clinical Care Fundamentals Refresher/Update
This two-day Refresher/Update training module was developed in response to a high demand for refresher training, as well as the need to update already trained healthcare staff on the most recent changes to the national treatment guidelines. Incorporating information from the new guidelines along with care and treatment fundamentals, the training covers HIV testing, ARV therapy eligibility, principles of ARV therapy, management of toxicities, management of treatment failure, PMTCT, and treatment of TB and other opportunistic infections.

The module was first implemented in January 2008. All efforts will be made to re-train healthcare workers as quickly as possible in order to maintain the high standard of HIV/AIDS care and treatment in Botswana.

Medication Adherence Counseling
This three-day course is designed to enhance the adherence counseling skills of healthcare workers. Offered as a centralized training for nurses, pharmacy staff, and social workers from ARV treatment centers, Medication Adherence Counseling focuses on strategies to overcome potential barriers to adherence.

A combination of lectures, case discussions, role-playing, and interactive activities are employed to reinforce good counseling techniques and strengthen the participants' ability to devise and implement successful adherence interventions. Implemented in collaboration with the Botswana-Baylor Children's Center of Excellence, the course also includes teaching and case discussions about pediatric and adolescent adherence, as well as disclosure of HIV status for children, adolescents, and their families.

Advanced HIV/AIDS Care and Treatment
This advanced training is designed for physicians and pharmacists providing ARV therapy in Botswana. Course participants must have previously completed AIDS Clinical Care Fundamentals and be actively involved in an ARV clinic.

Training participants involved in clinical case discussions with on-looking KITSO faculty

Advanced HIV/AIDS Care and Treatment combines lectures and interactive case discussions to provide advanced and comprehensive training in ARV therapy, emphasizing treatment principles and strategies practiced world-wide and applying them to the Botswana setting. This course familiarizes participants with the full complement of ARV drugs and provides strategies for the management of treatment failure, interpretation of drug resistance assays, designing of "salvage" regimens, and understanding short- and long-term ARV side effects and toxicities. Course content equips clinicians with the skills and knowledge necessary to manage complicated patients and provide guidance and support to their colleagues, thereby strengthening the growing HIV treatment expertise in Botswana's healthcare sector.

Advanced HIV/AIDS Care and Treatment covers adult, adolescent, and pediatric HIV care. Special emphasis is placed on primary care for HIV-infected children and on disclosure issues, especially in regards to children and adolescents.

Each advanced course also provides updates on relevant research and clinical trials conducted internationally and in Botswana as well as summaries of recent international HIV/AIDS meetings.

Introduction to AIDS Clinical Care
In 2009 this satellite training module was upgraded from a one-day to a two-day training. The training provides nonmedical professionals with a basic understanding of identification and management of HIV/AIDS in Botswana.

Course content includes an introduction to HIV pathophysiology and immunology and information about testing, eligibility and referral for ARV therapy, identification of common ARV side effects, the importance of medication adherence, counseling and referral for PMTCT, and post-exposure prophylaxis. This course is suitable for general health educators, family welfare educators, and lay counselors and social workers. Since 2006, Introduction to AIDS Clinical Care has been implemented at ARV sites by the BHP–PEPFAR Master Trainer Program.

Sexual and Reproductive Health in HIV Infection
This new module provides training for health professionals providing counseling and care in sexual and reproductive health issues for persons living with HIV. The course will empower health care workers to identify and manage sexual and reproductive health issues pertaining to HIV infection, such as STIs, family planning including conception and contraception, sexual dysfunctions, menopause, pregnancy and PMTCT, and HIV prevention. Implementation of this module started 2010.

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Reference Corners and Resource Materials
KITSO-BHP has established "reference corners" in the medical libraries of Botswana's two referral hospitals, Princess Marina Hospital and Nyangabgwe Hospital. Resources in these reference corners include textbooks, medical reference guides, specialized journal subscriptions, and relevant handbooks and guidelines.

KITSO-BHP has also provided each district hospital in Botswana with a laptop computer and an LCD projector for in-service staff education.

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Collaborations
KITSO-BHP owes its success both to ACHAP for its financial support and to the dedicated faculty members from the Botswana MOH and Ministry of Local Government, the ACHAP Clinical Preceptorship Program, Botswana-Baylor Children's Clinical Center of Excellence, BHP, University of Pennsylvania, the PEPFAR Master Trainer Program, the Private Practitioner Association of Botswana, and the World Health Organization.

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Accomplishments
While much remains to be done, KITSO-BHP takes pride in the work that has been accomplished in training healthcare professionals in Botswana. KITSO-BHP commends the leadership of the MOH, the commitment of Botswana's healthcare workers, the support of stakeholders and collaborators, and the dedication of the KITSO faculty and team for making such achievements possible.

Accomplishments include:

Continued didactic training support for treatment teams from ARV sites

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KITSO-BHP Team

Monitoring and Evaluation (M&E)

From its inception, KITSO-BHP has carefully incorporated monitoring and evaluation tools into its training formats to assess the quality and integrity of the program's structure, content, and implementation. This commitment to assessment and evaluation has allowed the KITSO-BHP program to quickly adapt to changing national healthcare guidelines, stakeholder advice, faculty and participant feedback, and the recommendations of external evaluators.

A Long-Term Evaluation was conducted in 2006 to assess the impact and reach of KITSO-BHP training. Site leaders from 17 ARV sites were interviewed and 494 former course participants completed survey questionnaires and knowledge assessments. The final evaluation report was released by the MOH in January 2008.

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