experience from Lesotho Dr Hind Satti Director Partners

experience from Lesotho Dr Hind Satti Director Partners In Health Lesotho

Lesotho: Basic Facts • Landlocked country located within South Africa (bordering Free State and Kwa. Zulu-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 Programme • A comprehensive response to MDR-/XDRTB 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 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

Highlands

Lowlands

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.

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

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

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.

National TB Reference Laboratory

Whatever it takes

Botsabelo MDR-/XDR-TB Hospital care for very sick ones

Patient Characteristics • Approximately 78% HIV-positive with advanced AIDSdefining 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 assistance shelter, transportation and food

MDR-TB/HIV • 100% HIV testing during the first visit. • Early initiation of HARRT for MDRTB/HIV (10 -21 days), regardless of CD 4 count. • Aggressive management of side effects. • Home assessment visit before initiation. • Household contact screening and testing for TB and HIV.

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 • International training/ attachment for HCW and TB managers. • 2010 - 5 countries - 68 HCWs • Training materials with WHO. • Technical assistance to other countries.

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