Lesotho / Bo-Mphato Litšebeletsong tsa Bophelo

PIH's project in Lesotho is our second in Africa and our first in a country suffering from extremely high prevalence of HIV. Approximately one quarter of Lesotho's adult population is HIV-positive and life expectancy in the tiny mountain kingdom has plummeted to less than 35 years. In addition, the Basotho people are being ravaged by a second epidemic. Lesotho's TB rate is the fourth highest in the world, and TB spreads rapidly and is particularly deadly where many people's immune systems have been weakened by HIV. The PIH project in Lesotho was launched in 2006 following an invitation from the government of Lesotho and consultation with our partners in Rwanda, the Clinton HIV/AIDS Initiative (CHAI), about where to replicate that successful model elsewhere in Africa.

The rural initiative

	PIH Lesotho operates 7 rural mountain health centers.

As in Rwanda, PIH began with a focus on bringing HIV and TB care and treatment to poor, rural communities that have largely been neglected by other AIDS programs and non-governmental organizations. In the case of Lesotho, that means remote villages high in the mountains that are often accessible only by single-engine propeller aircraft or on horseback. Our first project site in the mountain village of Nohana is less than 70 miles from the nearest hospital in Mohale's Hoek. But the terrain is so rough and the road in such ill repair that it takes eight hours to reach the clinic by car.

Since arriving in Nohana in June 2006, PIH has been providing clinical support, training for nurses and village health workers and medications for treatment of HIV/AIDS and tuberculosis. The program also offers outreach and treatment for prevention of mother-to-child transmission of HIV and conducts home visits and educational meetings in villages served by the Nohana health center. With help from an agreement with the World Food Program, PIH is also providing nutritional support for HIV and TB patients, malnourished children and others who show clinical signs of malnutrition.

A small office in the capital of Maseru coordinates logistics, procurement and communications for a network of rural community health centers. As of the end of 2009, PIH was working in 7 of these health centers, including Nohana, Bobete, Nkau, Lebakeng, Tlhanyaku, Methalaneng, and Manamaneng, which serve a combined population of more than 300,000 people. Transport of people and supplies is provided through partnerships with the Lesotho Flying Doctors Service (supported by the Ministry of Health and Social Welfare) and Mission Aviation Fellowship.

Drug-resistant tuberculosis

With funding from Open Society Institute (OSI) and in partnership with the Ministry of Health, in 2007 PIH launched Lesotho’s first-ever treatment program for multidrug-resistant tuberculosis (MDR-TB), recognizing the extremely high rates of HIV/TB coinfection in the country, and the growing MDR-TB problem. With the recent outbreaks of extensively drug-resistant TB (XDR-TB) in Southern Africa, PIH’s expertise in drug-resistant TB (and in dealing with HIV/TB coinfection) was a perfect fit in neighboring Lesotho.

Prior to the launch of the PIH MDR-TB project in Lesotho, the country lacked the resources to diagnose drug-resistant TB and monitor its prevalence. Even worse, there was reason to believe that the vast majority of MDR-TB patients in Lesotho are also coinfected with HIV. Using drug-resistance data from KwaZulu-Natal, a neighboring province of South Africa, and applying it to the 2005 incidence of TB in Lesotho, an estimated 950 new MDR-TB patients will be diagnosed in Lesotho every year. This number does not account for the existing cases. Of these 950 patients, using estimates from the Lesotho National Tuberculosis Programme, up to 90 percent are also infected with HIV.

In 2007, PIH has focused on refurbishing the national TB laboratory and opening a new MDR-TB hospital in the capital city, Maseru. Previously a leprosy hospital, Botsabelo Hospital was converted into a 20-bed facility for the treatment of critically ill MDR-TB and MDR-TB/HIV coinfected patients, so that they can receive round-the-clock care. Renovations have been extensive, including the installation of infection control mechanisms, family/visiting areas and a family room for patients, and other improvements to make the hospital a pleasant and humane environment for patients undergoing long-term treatment. This facility also serves as PIH’s center for training doctors and nurses in the management of MDR-TB/HIV coinfection. The first patients were admitted to the hospital at the end of September 2007 and since then the facility has been consistently filled to capacity.

At the same time that the hospital was being renovated, PIH also launched MDR-TB treatment at the community level. By the end of 2007, 42 MDR-TB patients were enrolled on therapy. Most of the patients are men, reflecting the impact of seasonal migration of many Basotho men to South African mines for work. The majority are HIV coinfected, suffering from advanced AIDS as well as severe malnutrition. Patients come from all over the country, including the country’s most isolated rural mountain districts. By the end of 2009, over 370 patients had been enrolled on treatment.

As PIH has done elsewhere, MDR-TB treatment is mostly provided at the community level, supported by paid and carefully trained community health workers who visit patients in their homes twice a day. Those patients who are very sick and require immediate clinical care are hospitalized at Botsabelo Hospital and discharged after improvement. Others are not admitted to the hospital but require frequent clinical visits to Maseru. Those who live too far away to make regular trips to the capital city are housed in PIH-supported temporary accommodations until they are stabilized and can be returned home to continue care in their own community.