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experience from Lesotho

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Presentation on theme: "experience from Lesotho"— Presentation transcript:

1 experience from Lesotho
Dr Hind Satti Director Partners In Health Lesotho

2 Lesotho: Basic Facts Landlocked country located within South Africa (bordering Free State and KwaZulu-Natal) Population 1.8 million 12,275 TB new cases notified in 2009 Over 2000 re treatment cases Estimated annual TB incidence for all cases is 691 per population HIV prevalence rate: 23.2% in 2005 80% of TB cases are HIV positive (NTP 2008)

3 Courtesy of Tara Loyd Children in a village.

4 Lesotho MDR-TB Programme
A comprehensive response to MDR-/XDR-TB in Lesotho, established by the MOHSW. International partners include PIH,OSI, WHO, FIND. Community-based treatment and care model that includes all 10 districts First patients enrolled in August 2007; over 500 patients enrolled to date

5 Case Detection All HCWs including NTP staff
TB/HIV coordinators/Officers at district hospitals Health centre nurses providing HIV/TB care Routine HIV screening of MDR-TB patients, partners, family members Protocol for “medium-risk” and “high-risk” Sputum sent to national TB laboratory Screening of household contacts



8 Highlands Many small highland villages are comprised of only 7-12 huts, and most have neither roads nor vehicles. Travel in the highlands is most often on foot or by horseback – and is made more difficult by the mountainous terrain, sudden snow, and abundance of rivers and streams.

9 Lowlands There are approximately 2 million Basotho who live in Lesotho. Most of Lesotho is rural highlands, but even in the western lowlands the population is quite scattered. The overall population density is 70.2 persons square kilometer (181 per square mile). However, since 85 percent are subsistence farmers, the rural population density of 461 persons per square kilometer (176 per square mile) of arable land clearly reveals a critical land shortage. This expanding population is pushing settlements, grazing, and cultivation into the marginal higher elevations and more arid eastern parts of the kingdom. The resulting overgrazing and soil erosion accompanying this land use is perhaps the most serious problem facing Lesotho. Maseru, on the western border with South Africa, is the capital city, and home to approx. 180,000 Basotho. Maseru is the only large city in Lesotho. Only 7% of the population in Lesotho has electricity; only 12% have running water. Some 70% of the total population lives in the fertile lowlands, where the land can be most readily cultivated; the rest is scattered in the foothills and the mountains. It was estimated by the Population Reference Bureau that 28% of the population lived in urban areas in 2001. Of the 10 districts, four (Leribe, Berea, Maseru and Mafeteng) are considered lowland and six highland. Each district has a main town and a district hospital. A large portion of the population resides in the western lowlands, and the rest is scattered throughout the mountainous highlands.

10 Selection of CHWs and Supervisors
Selection is done at the community level in the presence of the chief during a public gathering. The selected member must be trusted and respected by the community. The community health worker must be literate and must be less than 60 years old.


12 Training of Treatment Supporters
Knowledge TB OIs HIV Drug resistance Drugs/side effects Screening for malnutrition and chronic conditions Skills DOT, defaulter tracking Psychosocial support Infection control in the home Screening family for TB and HIV Screening for DM, HTN and malnutrition Accompany pregnant women to the clinic for ANC and delivery

13 Selection of Treatment Supporters
Lives close to the patient Accepted by patient and family Willing to support patient Willing to accompany patient to all clinical visits Attend monthly trainings Willing to provide psychosocial support

14 Role of Treatment Supporter
Observe all doses Report side effects Provide injections. Accompany patient for clinical evaluations Screen for TB and HIV in household contacts. Offer psychosocial support to the patient and the family.

15 National TB Reference Laboratory

16 Whatever it takes

17 Botsabelo MDR-/XDR-TB Hospital care for very sick ones

18 Point #5: Botsabelo Hospital
Some patients should not be treated in their homes.

19 Patient Characteristics
Approximately 78% HIV-positive with advanced AIDS-defining conditions Severe malnutrition Multiple failed TB treatment regimens Extensive TB disease Mostly smear-positive

20 The Perfect Storm Disease Poverty HIV TB Malnutrition 1-room shelter
Poor hygiene Inadequate clothing Two little boys and their aunt who is on TB treatment have been stricken by hunger and poverty, they are staying within the house pictured above.

21 Social assistance shelter, transportation and food

22 MDR-TB/HIV 100% HIV testing during the first visit. Early initiation of HARRT for MDRTB/HIV (10-21 days), regardless of CD4 count. Aggressive management of side effects. Home assessment visit before initiation. Household contact screening and testing for TB and HIV.

23 150 patients were enrolled during 2008:
2008 cohort analysis 150 patients were enrolled during 2008: 65% treatment success 34% death 0% default 0.7% (1) failure 0.7% (1) transfer out

24 Building capacity International training/ attachment for HCW and TB managers. countries - 68 HCWs Training materials with WHO. Technical assistance to other countries.

25 Conclusion Management of MDR-TB in high HIV-prevalence settings is challenging but possible M&E Empiric treatment of MDR-TB is needed to decrease early mortality Community engagement is critical. Community-based MDR-TB/HIV allows for rapid enrollment and closer monitoring of side effects

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