The University of Pennsylvania (Penn) has been in Botswana for five years. The program began at the invitation of ACHAP (African Comprehensive HIV/AIDS Partnership), which is a collaboration between the Government of Botswana, the Bill and Melinda Gates Foundation and the Merck Foundation. Penn physicians were invited to help develop and implement the Botswana national HIV treatment and prevention programs and to assist in the training of local providers on the management of HIV infected patients. We were attracted to Botswana because of the determination of the government to conquer HIV/AIDS in a country with a prevalence of HIV that is among the highest in the world. Thirty-four percent of adults between the ages of 15 to 49 are infected. The total population of the country is 1.7 million, with an estimated 500,000 infected persons. Over the ensuing five years the Penn program has expanded to involve the following four components.

1. Clinical Care and Education: In 2004 Penn signed a Memorandum of Understanding with the Ministry of Health in Botswana to participate in medical care and educational programs at the Princess Marina Hospital in the capital city, Gaborone. This was later expanded to include the Nyangabgwe Referral Hospital in Francistown, the second largest city as well as other district hospitals in Botswana. In 2004 Penn received funding from the US Public Health Service through a program entitled PEPFAR (President’s Emergency Plan for AIDS Relief) that covers 16 affected nations, including Botswana. The PEPFAR funds currently support six full time Penn physicians in Botswana, four of whom are located in Gaborone, the capital city and two in Francistown. These physicians provide inpatient care on the medical wards at Princess Marina and Nyangabgwe Hospitals, they provide HIV care in the outpatient clinics and they perform outreach inpatient and outpatient care at nine surrounding district hospitals. In addition, Penn physicians run a referral clinic for complicated HIV/TB co-infected patients. The Penn physicians are directly involved in training the local providers with daily “bedside” teaching and in supervising four weekly educational conferences.

2. Collaborations with the University of Botswana (UB): In September 2006, the UB and the University of Pennsylvania signed a Memorandum of Understanding to establish collaborations in medicine, nursing and other disciplines at the two institutions. The UB decided to form a new medical school that will enroll its first undergraduate class in January 2008. Previously, the UB was sending approximately 50 students a year to train in medicine in South Africa, Australia or Great Britain. Only approximately 10% of these students were returning to Botswana to practice medicine. This trend is now changing and in January 2007, approximately 20 Batswana medical students are expected to return to Botswana for internship training at the main referral hospitals. Penn has been invited to take a leadership role in developing the curriculum for a rotating internship at the teaching hospitals. Penn is also helping to develop the post-graduate residency programs in Internal Medicine and other specialties for the new medical school.

Other Schools at the University of Pennsylvania have developed collaborations with the UB, including the School of Nursing, the Wharton Business School, and the School of Arts and Science. In January 2007, Penn undergraduates will participate in “Semester Abroad” experiences in Botswana for the first time.

3. Global Health Experience for Penn medical Students and Residents: In academic year 2006-07, approximately 35 fourth year medical students will spend 6-week electives working as sub-interns on the medical wards in Botswana at the Princess Marina Hospital. In addition, approximately 12-16 third year Internal Medicine residents, and a hand-full of infectious disease fellows, neurology residents, obstetrics, and gynecology residents, dermatology residents, and emergency medicine residents will do electives in Botswana, which has become the most exciting and popular location for experience in International Medicine for Penn trainees. Penn rents three 3-bedroom apartments and one house in Botswana for the medical students, residents and short-term visiting faculty. Many of these Penn trainees have described this opportunity as the most important experience of their medical career.

4. Center for AIDS Research (CFAR) Programs: Penn is one of 19 CFARs in the USA. The goal of the CFARs is to establish Core facilities to promote HIV research. Penn has established a CFAR Core in Botswana to support clinical and translational research studies. The Core supports study nurses and a microbiology technician to help with sample collection and processing, human subjects approvals, informed consent, and identifying subjects for research studies. Through the activities of the CFAR Core in Botswana a growing number of Penn and Botswana researchers are participating in HIV research. Projects include a study of TB and HIV co-infection, an analysis of predictors of treatment success and treatment failure in subjects on antiretroviral medications, an evaluation of the causes of an unusual ocular tumor seen in HIV infected subjects, and an assessment of the causes of meningitis in patients admitted to the Princess Marina Hospital. During the current academic year, approximately 5 Penn medical students will spend 6 weeks to one year participating in the various research programs. Our research in Botswana focuses on medical issues of great importance to the country.

Three in-country staff, including an In-Country Program Director, a Head of Operations and a Program Coordinator support the Penn Botswana program. Their roles are to seek out new initiatives for Penn in collaboration with governmental departments and to ensure the successful operation of the existing programs. Approximately half of those persons who need HIV treatment are on therapy in Botswana. This compares very favorably to the sub-Saharan average of 10%. Our progress has been exciting, rewarding and stimulating and has contributed to the reduced prevalence of HIV in Botswana and to enhancing the hopes of its citizens.

Written by Harvey Friedman, MD, Director of Penn-Botswana Program