Integrated Management of HIV Prevention and Treatment in Lesotho Dr Limpho Maile MD Mmed Sexual Health International HIV and AIDS Conference August 2006 Toronto, Canada

Lesotho Know Your Status (KYS) Campaign Plan Leave no Mosotho out.....every life counts! Universal Access to HIV Testing and Counselling in Lesotho THE GATEWAY TO HIV PREVENTION, TREATMENT, CARE AND SUPPORT

From the Universal Declaration of Human Rights “Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing, and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”

Know Your Status: Why We Can’t Wait The world is watching, for good reason KYS can be the most effective way of protecting the human rights of Basotho KYS links treatment and prevention in a novel and potentially revolutionary way Universal Access will be impossible without bold initiatives like KYS Implementers and partners must show our commitment to the world through our actions – the funding will flow Our sense of urgency must match the urgency of the epidemic

Lesotho- Know Your Status campaign: The questions 1. What it is KYS? 2. When and where? 3. How are you going to do it? 4. With whom? 5. What does it need to be built in the health facility to take over HIV+ and HIV- clients?

What is “Universal Access to HIV Testing and Counseling” in Lesotho ? A shared national vision to provide HIV testing and counseling services to all Basotho women, adolescents and men, as an "the gateway" to HIV prevention, treatment, care and support

What is the “Know Your Status” campaign main objective? All people above 12 years of age living in Lesotho will know their HIV status by the end of 2007, so that those who are negative remain negative and those who are positive can be treated and live productive lives.

Why is it necessary for all people living in Lesotho to know their HIV status? HIV rates in Lesotho are threatening the future of the country. Knowledge of HIV status combined with on-going counselling can impact positively on behaviour, especially for those who test positive HIV and AIDS prevention, care, treatment and support at the health centers are being scaled-up through IMAI. Greater numbers will be able to access these services. Early diagnosis of HIV and treatment will significantly ease the health sector's burden of caring for sick and dying HIV patients and decrease the number of new orphans.

What is the campaign's strategic approach? Communities will choose how testing and counselling should be progressively rolled out Community mobilization and education will follow Every household will be offered an HIV test and personal counselling Everybody tested and counselled will be referred to post-test services, according to their HIV status Using IMAI, prevention, treatment care and support services will be concurrently scaled up at the health centre level throughout the country to cover children and adults. This is critical to the success of the KYS campaign

HIV Testing and Counselling Service Provision 3,600 community health workers will be trained in HIV testing and counselling Five community members per village, including PLWHA and expert patients, will be trained in on-going counselling and HIV education Quality control assured through monitoring according to existing national standards

Balancing the “Right to Know” and the “Right to say No" HIV testing and counselling in Lesotho is never mandatory. All Basotho will be offered HIV testing and counselling Those providing HIV testing will receive training on how to obtain informed consent prior to testing and ensure client understanding

Strategic Objective 1 Create a policy environment that enables people in Lesotho to know their HIV status Progress: Developed HTC policy through consensus and participatory process with key stakeholders HTC policy awaits approval by Cabinet Media and advocacy campaign to publicize strategy have been undertaken

Strategic Objectives 2 & 3 2. To build widespread national support for, and local ownership of, the KYS campaign Progress : National, district and community consultation process conducted countrywide Partnerships to support KYS campaign strengthened 3. To build knowledge, shift attitudes and influence behaviour on HIV AIDS, particularly HTC  Progress: Formative research to guide communication strategy conducted Expanded capacity of media to carry out campaign Produced audiovisual and print campaign support material

Strategic Objectives 4 & 5 4. Expand human capacity to conduct HIV testing and counselling Progress: Training of community health workers initiated Strengthen district management capacity Training of lay counsellors and educators is ongoing Working with key partners to build human capacity 5. Expand access to HIV testing and counselling especially at community level Progress: House to house offer of HIV testing & counselling by community health workers from within/outside community initiated in one district Provision of mobile and outreach testing and counselling services Expand HTC in all health facilities ongoing

Strategic Objectives 6 & 7 6. Strengthen logistics and supply management Progress: Procured and distributed test kits and consumables First test: DETERMINE Positive results confirmed with DOUBLE CHECK ELISA testing for quality assurance of test kits Equip districts with vehicles to manage campaign – not yet done 7. Strengthen post-test services for HIV negatives and positives Progress: Strengthen referral system - done Provide support for HTC counsellors on going Scale-up IMAI essential package for prevention, treatment, care and support within health centres, conducted in 8 districts.

Strategic Objectives 8 & 9 8. Strengthen supervisory system at district and community levels Progress: Set up supervisory system for community level HTC Strengthen supervisory capacity of District Health Management Teams through IMAI training - conducted Assure quality control of HIV testing – quality control system in place 9. Strengthen monitoring and evaluation of HIV testing and counselling services Progress: Map service availability, including prevention HIV/ART Patient monitoring system in place Implement M and E system Monitor and track HIV epidemic, including behavioural data – not yet done Evaluate the KYS campaign on going

Strategic Objective 10 Assure independent oversight of “Know Your Status" campaign to ensure rights of community members are protected Formed independent National HTC Monitoring Committee (NHMC) composed of members of civil society at national level which report directly to the National AIDS Commission Formed District HTC Monitoring Committee (DHMC) which report to national level on suspected abuses (forced disclosure, violence, etc.) Form Community HTC Monitoring Committees (CHMC) to provide oversight monitoring of campaign roll-out at village level – not yet done Orient all committee members in HTC human rights issues - ongoing

Strategic Objective 11 Mobilize necessary resources to fully implement the “Know Your Status” campaign and IMAI scale up at national, district and community levels Progress: Engage partners to second staff and services for implementation of campaign – on going Engage donors to fund campaign – on going Engage private sector to take ownership and support campaign with both financial and in-kind support – on going

How to achieve impact? Must assure that everyone who tests positive or negative has access to essential prevention, treatment, care and support services within the catchment area Community-level mobilization, education and support groups Safer sex counselling and condoms Diagnosis and management of STIs Positive prevention (prevention for PLWHAs) Care for opportunistic infections Antiretroviral therapy Palliative care Nutritional and psychosocial support IMAI

How to bring the services down to the health centre? April 2005: IMAI guidelines adapted May 2005: ART District Coordinator and Patient Monitoring training June 2005: IMAI TOT and training of clinical teams from each of the health service (this included pediatric and mental health module) November 05: All hospitals providing ART November 2005: Clinical mentoring programme begun December 2005: Launch of KYS and of the operational plan (including IMAI scale up) January 2006: Scale up of training to all health centres 2006-ongoing: Expand clinical mentoring and follow-up of clinical teams in the whole country Universal access to quality services close to patient home

Levels of care for ART

General Community Support Home Care Patient and Treatment supporter Clinical Team COMMUNITY PREPAREDNESS - Support Groups, Advocacy Groups, - Education & destigmatisation - Normalisation of HIV - Scale up Testing & Counselling HOME PREPAREDNESS *Family members and visiting carers prepared for supportive and palliative care, nutritional support, adherence support INDIVIDUAL PREPAREDNESS - Patient/client self-management -Treatment supporters for one-on-one support - Psycho-social support - Other adherence support ADVANCED INDIVIDUAL CAPACITY * Expert patients as trainers * ART aid Help with facility management *Weigh, triage for self-limited illness & side effects Community Intervention in HIV/AIDS Services

The National Scale-up Plan for ART services in Lesotho Expansion of ARVs is in 4 Phases Phase I: District Hospitals Phase II: Filter Clinics and Private Clinics Phase III: Health Centres Phase IV: Health Posts and Community

The National Scale-up Plan for ART services in Lesotho Expansion of ARVs is in 4 Phases Phase I: Completed by Dec 2005 Phase II: Filter Clinics Completed Jan 2005 Private Clinics in progress (14) Phase III: In progress (34) Phase IV: In progress (within the rural initiative programme) Currently there are 57 functional ART sites in Lesotho

HIV Testing and Counselling Statistics March 2006June 2006Jul ‘04-Jun ‘06 (cumulative) Pre-test counselled Tested Post-test Total HIV Total HIV Females Males Females Males

Number of Patients on ART by Districts December 2005 to June 2006

Summary of HIV Interventions Statistics end of June 2006 Total number of clients on chronic care – Baseline of people on ARVs prior to November 2004 through the private sector – Cumulative number of adults ever on ART – Total number of males currently on ART – Total number of females currently on ART – Total number of pregnant females currently on ART – 93 Total number of children 0-14 years currently on ART – 726 Total number of clients ever put on ART (Adults and Children –

Conclusions on ART By the end of June PLWHAs on ART countrywide Adults on ARVs PLWHAs Children on ARVs 726 PLWHAs The MOHSW ART target for 2006 was VCT coverage by June 2006 – 8 % PMTCT coverage by June 2006 – 7% Proportion of people in need of ART by the end of June 2006 accessing treatment is 30.2% (42 640)

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