experience from Lesotho experience from Lesotho

Dr Hind Satti

Director Partners In HealthLesotho

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)

Courtesy of Tara Loyd

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

HighlandsHighlands

LowlandsLowlands

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.

National TB Reference LaboratoryNational TB Reference Laboratory

Whatever it takesWhatever it takes

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

Social assistanceSocial assistanceshelter, transportation and food shelter, transportation and food

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