Lesotho: A "Well-Spring of Hope" in a Mountain Kingdom Haunted by TB/HIV

The beautiful, mountainous landscape is visible through the windows, but the patients here are all in serious condition, suffering from tuberculosis (TB), the leading cause of death of people living with HIV in Lesotho.

The sound of coughing fills the short passageway outside the female ward of Scott Hospital in Morija, Lesotho, where Doctors Without Borders/Médecins Sans Frontières (MSF) and the national Ministry of Health manage a program locals have dubbed “Selibeng Sa Tsepo,” or “wellspring of hope.” Apart from the nursing staff in the ward, there are no visitors. The beautiful, mountainous landscape is visible through the windows, but the patients here are all in serious condition, suffering from tuberculosis (TB), the leading cause of death of people living with HIV in Lesotho.

Mampho Ratsese, 57, is one of the most recent arrivals to the ward. When she came in last month, she presented the classic symptoms of TB–the night sweats, the incessant coughing, the fever and the breathlessness. That day, a chest x-ray revealed the TB infection in her pleural cavity, just outside the lungs (also known as extra-pulmonary TB pleural effusion, it causes excessive fluid to accumulate in the area surrounding the lungs, which severely impairs breathing).

“There are two types of TB,” explains Dr. Laura Trivino Duran, who heads the MSF TB program in Lesotho. “The most common is pulmonary TB, mainly affecting only the lungs. And the other type is extra-pulmonary TB, which can be found in all other organs of the body. The most common extra-pulmonary TB infection is located in the pleural cavity. Other forms are found in lymph nodes, abdomen, meninges of the brain, and joints or bones. Extra-pulmonary TB is usually a more severe type of TB and sometimes patients need to be admitted to the hospital. Anti-tuberculosis treatment can take up to 9 to 12 months in severe cases.”

Mampho is among the more than half of Lesotho’s 1.9 million people who are living below the poverty line in one of the world’s poorest nations. An already difficult economic situation can become a crushing burden to bear when combined with the country’s high rates of TB, HIV, and HIV/TB co-infection. The country has the third-highest HIV prevalence in the world (after Swaziland and Botswana) and the fourth-highest rate of TB incidence at 637 cases per 100,000 people per year. Disturbingly, every year approximately 18,000 people (about 1 percent of the population) die due to AIDS-related complications, including TB and multi-drug resistant TB (MDR TB). But perhaps most worrying of all is the HIV-TB co-infection rate: 90 percent of active TB patients also have HIV.

For Mampho these are not just statistics, but cold, hard reality. In 2007, a year after her husband died—possibly due to HIV/AIDS-related complications—she tested HIV positive. A mother of six, she has already lost two children to TB. “It has been difficult ever since my husband died,” she says. “He was the breadwinner. But now, during my treatment in the hospital, food is scarce. There’s no one to seek help with. I even add a burden to my daughter, who is already struggling with her own family.”

To relieve the pressure of the fluid build-up in Mampho’s pleural cavity where the extra-pulmonary TB infection is located, doctors have inserted a tube into her chest to extract the fluid. She initially appeared alert and resilient, but three days later, she seemed frail and weak.

In 2006, lay counselors—often HIV and TB-HIV patients themselves—were recruited and trained to give advice to patients on treatment regimens and adherence. Their help is needed. “I don’t yet understand fully what TB means and what it is all about,” Mampho says. “All I know is that TB is transmitted by air and from others. Despite my current condition, I still have hope. This is not the worst thing I have been through. The death of my husband was the saddest and most difficult of all times I went through, as no one can look after me. But I remain hopeful.”

MSF has been working in Lesotho since 2006, pioneering decentralization of access to health care by employing strategies such as “task-shifting,” which empowers nurses to make nurse-driven ART and TB initiations and creates a way to overcome the acute shortage of doctors in the country. This novel strategy allows full integration of HIV and TB services at the primary healthcare location. MSF is primarily providing support to Scott Hospital in Morija, and to 14 clinics in the Mafeteng and Maseru districts.