Lesotho: Basic FactsLesotho: 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 100 000 population • HIV prevalence rate: 23.2% in 2005• 80% of TB cases are HIV positive (NTP 2008)
Lesotho MDR-TB ProgrammeLesotho 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
Case DetectionCase 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
Selection of CHWs and Selection of CHWs and SupervisorsSupervisors
• 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.
Training of Treatment SupportersTraining of Treatment Supporters
KnowledgeTB OIsHIVDrug resistanceDrugs/side effectsScreening for
malnutrition and chronic conditions
SkillsDOT, 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
Selection of Treatment SupportersSelection 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
Role of Treatment SupporterRole 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.
Botsabelo MDR-/XDR-TB HospitalBotsabelo MDR-/XDR-TB Hospitalcare for very sick ones care for very sick ones
Patient CharacteristicsPatient Characteristics
• Approximately 78% HIV-positive with advanced AIDS-defining conditions
• Severe malnutrition• Multiple failed TB
treatment regimens• Extensive TB disease• Mostly smear-
positive
The Perfect Storm
• Disease– HIV– TB– Malnutrition
• Poverty– 1-room shelter– Poor hygiene– Inadequate
clothing
MDR-TB/HIV 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.
2008 cohort analysis 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
Building capacity Building capacity
• International training/ attachment for HCW and TB managers.
• 2010- 5 countries - 68 HCWs• Training materials with WHO.• Technical assistance to other
countries.
ConclusionConclusion
• 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