Brussels/Maseru - In January 2006, MSF launched a new HIV/AIDS programme in Lesotho, a land-locked country in the southern tip of Africa completely surrounded by South Africa.

The programme aims to provide free HIV/AIDS care and treatment to as many people as possible in a rural health district south of the capital, Maseru. It also aims to strengthen the capacity of local health workers to reduce HIV-related deaths and improve and extend the lives of people with HIV/AIDS.

Lesotho has the third highest HIV prevalence in the world. With 29.8% of adults infected, it comes after only Botswana and Swaziland, and is the poorest of the three. Around 330,000 adults and 27,000 children have HIV/AIDS out of a total population of just over 2 million.

Approximately 29,000 people died of AIDS in 2003, representing nearly 1.5% of the entire population.

General poverty and migrant labour are driving forces behind the HIV epidemic, and there are no signs that it is stabilising. HIV/AIDS is having a clear and devastating impact on all aspects of society, including health, education, agriculture and general economic development.

In Lesotho, about one sixth of those infected with HIV/AIDS — nearly 60,000 people — are in urgent need of antiretroviral therapy (ART). Today only around 8,000 people are estimated to be on ART. Despite the numbers, there is serious commitment on the part of the government to address the country's HIV/AIDS crisis and expand access to treatment.

Assessment and first steps

In August 2005, MSF conducted an exploratory mission to better understand the overall needs, general context and local response to HIV/AIDS. The team met with national authorities, UN agencies, people living openly with HIV/AIDS as well as treatment providers, and carried out site visits to various health facilities.

This assessment led to the decision to start the programme, and also highlighted a series of challenges to scaling up HIV/AIDS treatment in Lesotho.

These include a severe human resource crisis in the health sector, complex doctor-centred and hospital-based trainings, guidelines, and approach to HIV/AIDS treatment, high HIV-related stigma and low awareness about treatment among people living with HIV/AIDS (PLWHAs), and prohibitive 'user fees' at all levels of care.

"The overall aim of the project is to reduce HIV-related morbidity and mortality in Lesotho through the implementation of free comprehensive HIV/AIDS care and treatment, including ART," explained Rachel Cohen, the project coordinator.

The target area is the Health Service Area (HSA) of Scott, surrounding the town of Morija, 40 km south of the capital, Maseru. This is a rural health district covering approximately 220,000 people. The objective is to implement a decentralised, nurse-oriented, community-based programme providing free HIV/AIDS care and treatment in the 14 health centres and hospital in Scott HSA, adapting the experience of MSF in Khayelitsha and Lusikisiki to the practical realities and constraints of this setting.

The MSF team is mainly composed of South Africans who have worked for MSF in Khayelitsha, South Africa, a township near Cape Town where MSF has been providing ART for the past five years.

In January 2006, MSF assembled a medical, logistical and administrative team and visited clinics throughout the HSA to carry out a preliminary assessment of; the clinical skills of the nurses; the range of services offered at the primary care level; and the basic clinic infrastructure (including drug availability, communications systems, transport of blood specimens, availability of electricity and clean water, etc.).

Cohen added that "We have also met with village health workers and members of support groups of people living with HIV/AIDS to get a sense of the extent of community involvement in HIV/AIDS in surrounding villages and begin preparing the clinics for the arrival of free comprehensive HIV/AIDS care and treatment in the coming weeks."

According to the Ministry of Health and Social Welfare, the MSF programme will be the first in Lesotho to decentralise comprehensive HIV/AIDS care and treatment, including ART, to the primary health care level and provide it for free to patients. The challenges of doing so will be enormous.

Building local capacity

In early February, MSF conducted a four-day training on management of ART at the primary health care level for nurses in the HSA. This was a follow-up to a five-day training on management of opportunistic infections and other HIV-related conditions that was organised in November 2005 and was attended by the same group of nurses.

Immediately following the training, MSF launched clinical activities in the hospital. A mobile team of one doctor and two nurses started visiting each health centre once a week to provide direct clinical care for HIV-positive people and offer on-the-spot supervision and training for nurses, village health workers, and other care providers.

The team is also rotating spending at least two days a week to attend to acutely ill patients and support staff at Scott Hospital in integrating HIV/AIDS care and treatment into existing hospital activities.

During this same week, MSF procured a shipment of essential medicines needed to prevent and treat opportunistic infections, received the first shipment of antiretroviral drugs, and purchased and arranged for installation of and training on the use of a new CD4 machine for the hospital laboratory, which will function as a reference lab for the entire health district.

In addition to providing ART, Cohen explained that "the main medical objectives are to promote and decentralise voluntary counselling and testing, to strengthen the existing prevention of mother-to-child transmission programme, to improve and decentralise the management of opportunistic infections-especially tuberculosis, which is the leading cause of death among people with HIV/AIDS - and to support HIV awareness, treatment education, and prevention at the community level."

It is hoped that MSF's presence in Scott HSA will not only reduce premature, avoidable deaths of individuals living with the virus but also, over the longer-term, help mobilise communities around HIV/AIDS treatment and strengthen the capacity of nurses, village health workers, and others to join together with people living with HIV/AIDS to improve and extend lives in the face of Lesotho's truly overwhelming HIV/AIDS emergency.