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