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Nurse-driven, community-supported HIV/AIDS care and treatment: 2 year antiretroviral treatment outcomes from a primary care level programme in rural Lesotho. Dr Lipontso Makakole, Bsc MD MPH Medical Superintendent, Scott Hospital Health Service Area, Lesotho

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  1. Nurse-driven, community-supported HIV/AIDS care and treatment: 2 year antiretroviral treatment outcomes from a primary care level programme in rural Lesotho Dr Lipontso Makakole, Bsc MD MPH Medical Superintendent, Scott Hospital Health Service Area, Lesotho Dr Helen Bygrave, MA MRCP Médecins Sans Frontières (MSF) 20 July 2009 IAS 2009 CAPE TOWN

  2. Background • Population: 1.8 million • HIV prevalence: 23.2% HIV prevalence (3rd highest) • 270,000 PLWHA • 80,000 in need of ART • TB incidence: >600/100,000 (4th highest) • AIDS leading cause of under five mortality (56%) • Life expectancy: 35.2 years • Catastrophic HR situation • 5 doctors/100,000 • 63 nurses/100,000

  3. Launched in 2006 Collaboration between GOL, Christian Health Association of Lesotho, and MSF Handover planned to MoHSW for mid-2010 Programme Setting: Scott Hospital Catchment Area Context Programme • Population: 200,000 • 35,000 PLWHA • 10,000 in need of ART (new criteria) • TB/HIV co-infection rate: >90% • Health facilities: • 102-bed district hospital • 14 rural health centres serving 941 villages

  4. Programme Approach Decentralisation to primary health care level at the outset Provide care & treatment closer to where people live Better utilise existing PHC capacity & staff Nurse-initiated and managed HIV care, including ART for adults and children Task-shifting from doctors to nurses Clinical mentorship by MSF mobile medical team Developing nurse-friendly guidelines and tools Strengthening PHC to ensure diagnosis and treatment of leading causes of mortality Nurses’ clinical management skills Additional capacity: new cadre of HIV/TB lay counsellors Laboratory capacity and specimen collection system Reinforcement of the drug supply system Working conditions Strengthening programme management capacity

  5. Patient enrolment 2006-2008 HIV CARE : 14864 ART: 4347

  6. TDF for first-line (TDF/3TC/EFV) June 2009 70% of new initiations Challenges on providing effective contraception Baseline and 6 monthly creatinine clearance calculations done effectively by nurses In nurse-led setting less side effects to monitor and simplified regimen Initiation of ART for CD4 <350 Implementation of state-of-the-art PMTCT protocol HIV DNA PCR testing for early infant diagnosis Paediatric AIDS care without specialists Key Innovations

  7. 37% of initiations in 2008 Stage I &II CD4 200-350

  8. PMTCT integrated into ANC in rural clinics BUT… Coverage only 70%

  9. Outcomes

  10. Conclusions Outcomes compare favorably with other cohorts in sub-Saharan Africa Nurse-led care enables increasing numbers of patients (adults and children) to access quality care & treatment in remote areas Feasibility to introduce TDF, initiation <350 and a multidrug PMTCT protocol in rural setting 2 challenges to highlight: Need innovative ways to improve retention in care for highly mobile population Address clinical & programmatic challenges for handover to MOH

  11. KEA LEBOHAACKNOWLEDGEMENTS:People living with HIV/AIDS and their familiesHealth centre and Scott Hospital staffHIV/TB Lay CounsellorsMSF LesothoMinistry of Health and Social WelfareChristian Health Association of Lesotho

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