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LesothoIn the "Mountain Kingdom" of Lesotho, life expectancy is only 35 years. HIV/ AIDS is a significant killer and over 23 percent of the adult population live with the disease. Most HIV/AIDS-related deaths are due to co-infection with tuberculosis (TB). The country urgently needs more health workers, having just five doctors and 62 nurses per 100,000 people. In January 2006, Doctors Without Borders/Médecins Sans Frontières (MSF) and the ministry of health and social welfare launched a joint program to provide HIV/AIDS care and treatment, including antiretroviral (ARV) therapy, at the primary healthcare level in rural Lesotho. The program was launched in Scott Hospital health service area, which includes a district hospital and 14 primary care clinics in remote rural communities, and has a catchment of approximately 200,000 people. In addition to general primary care, the clinics provide comprehensive HIV/AIDS services including ARV therapy, HIV testing and counseling, prevention of mother-to-child transmission, early diagnosis in infants, and management of opportunistic infections and co-infections such as TB. One-stop integrated services have been established for patients co-infected with TB and HIV. Among other steps taken to ensure the integration of TB and HIV/AIDS care, all HIV/AIDS patients are systematically screened for TB, and TB patients are routinely offered an HIV test. MSF is also working with local health authorities to strengthen the primary healthcare system by improving laboratory services, drug supply, infrastructure, and program monitoring and supervision. By December 2008, 39,500 HIV tests had been carried out since the beginning of the project in 2006, and more than 4,300 patients had been initiated on ARV therapy. The clinical outcomes for the first two years are quite encouraging: 86 percent of adults and 93 percent of children are still in care after 12 months on ARV therapy. In addition, HIV transmission from mother to child has been reduced to less than five percent for pregnant women who received preventative care. TB recovery has also improved, with treatment success rates reaching 78 percent in 2008. Decentralized careBecause the hospital-based ARV therapy clinics are so full, there are so few staff and many patients find it hard to reach or afford health care, MSF’s goal from the outset was to decentralize all HIV/AIDS care and treatment services to health center level. The objective has been to bring care and treatment as close as possible to those in need, and to ensure HIV/AIDS care is free. Nurses were trained to assume high levels of clinical responsibility for HIV/AIDS care, including initiating and managing ARV therapy for adults and children. Lay counselors, primarily people living with HIV/AIDS, were recruited and trained to reinforce clinic capacity and provide essential support in the delivery of HIV/AIDS and TB services, particularly treatment adherence. As of December 2008 there were 45 lay counselors working across the 15 facilities. Joseph Ramokoatsi, a lay counselor working at one of the mountain clinics, knows what it is like to live with HIV and commit to lifelong ARV therapy. "The work that I do here is my passion," he says. "When I tell my patients to take the antiretrovirals to feel better, they trust me because I am a living example. I tell them to be very committed to taking the antiretrovirals, and not to stop in spite of the side effects." MSF lobbied for the elimination of user fees at the primary healthcare level, and in the meantime subsidized all essential HIV/AIDS-related services in the Scott Hospital catchment area, including drugs and other commodities, lab investigations, equipment, and hospital fees. In January 2008, the ministry of health abolished all user fees at primary healthcare level and lowered the fees for other district-level services. However, the costs that remain, including hospital admission for HIV-positive patients not on ARV therapy, and for chest x-rays, are still obstacles to accessing care, including TB testing. The aim of the MSF-supported program in Scott Hospital was to develop a model that was replicable and sustainable in the long term while meeting ambitious early targets for ARV therapy enrollment. The first three-year phase of the program has now come to a close and the project has entered a handover phase, during which MSF will gradually transfer all responsibilities to the ministry of health and other local partners by late 2010. MSF has worked in Lesotho since 2006. |
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