Presentation on theme: "experience from Lesotho"— Presentation transcript:
1 experience from Lesotho Dr Hind SattiDirector Partners In HealthLesotho
2 Lesotho: Basic FactsLandlocked country located within South Africa (bordering Free State and KwaZulu-Natal)Population 1.8 million12,275 TB new cases notified in 2009Over 2000 re treatment casesEstimated annual TB incidence for all cases is 691 per populationHIV prevalence rate: 23.2% in 200580% of TB cases are HIV positive (NTP 2008)
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 districtsFirst 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 hospitalsHealth centre nurses providing HIV/TB careRoutine HIV screening of MDR-TB patients, partners, family membersProtocol for “medium-risk” and “high-risk”Sputum sent to national TB laboratoryScreening of household contacts
8 HighlandsMany 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 LowlandsThere 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 KnowledgeTBOIsHIVDrug resistanceDrugs/side effectsScreening for malnutrition and chronic conditionsSkillsDOT, defaulter trackingPsychosocial supportInfection control in the homeScreening family for TB and HIVScreening for DM, HTN and malnutritionAccompany pregnant women to the clinic for ANC and delivery
13 Selection of Treatment Supporters Lives close to the patientAccepted by patient and familyWilling to support patientWilling to accompany patient to all clinical visitsAttend monthly trainingsWilling to provide psychosocial support
14 Role of Treatment Supporter Observe all dosesReport side effectsProvide injections.Accompany patient for clinical evaluationsScreen for TB and HIV in household contacts.Offer psychosocial support to the patient and the family.
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 conditionsSevere malnutritionMultiple failed TB treatment regimensExtensive TB diseaseMostly smear-positive
20 The Perfect Storm Disease Poverty HIV TB Malnutrition 1-room shelter Poor hygieneInadequate clothingTwo 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/HIV100% 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 analysis150 patients were enrolled during 2008:65% treatment success34% death0% default0.7% (1) failure0.7% (1) transfer out
24 Building capacityInternational training/ attachment for HCW and TB managers.countries - 68 HCWsTraining materials with WHO.Technical assistance to other countries.
25 ConclusionManagement of MDR-TB in high HIV-prevalence settings is challenging but possibleM&EEmpiric treatment of MDR-TB is needed to decrease early mortalityCommunity engagement is critical.Community-based MDR-TB/HIV allows for rapid enrollment and closer monitoring of side effects