More mountains beyond

From zero to 160 in six months. For acceleration in treatment of HIV patients in an area where more than half the adult population may be infected, those are impressive numbers. And they represent just one striking measure of the remarkable record of achievements racked up by Partners In Health during our first six months working high in the mountains of the southern African country of Lesotho.

At the beginning of January, PIH’s project in Lesotho – known as Bo-Mphato Litsebeletsong tsa Bophelo in the national language, Sesotho – marked the completion of its first half year of work at the mountain health center in Nohana. At the same time, the project was gearing up to begin training and treatment at a second remote mountain site before the end of January. The first round of intensive training for village health workers in Bobete was scheduled for January 25-27, with testing and treatment to begin almost immediately after that.

The project’s achievements during our first six months in Nohana are breathtaking, as are the mountains and other obstacles that had to be surmounted to get there. By the end of December, the list of accomplisments included:

• more than 1,300 people tested for HIV
• nearly 600 HIV and tuberculosis patients diagnosed, monitored and receiving care and treatment
• 165 AIDS patients enrolled on antiretroviral therapy, including eight children under the age of 14
• a new waiting room constructed for patients who previously had to wait outdoors, often after traveling several hours on foot to reach the clinic
• one doctor in residence and frequent visits from other physicians at a clinic formerly staffed exclusively, and somewhat sporadically, by a nurse and nursing assistants
• more than 100 village health workers trained to help identify, educate, test and treat HIV patients in their communities, including 60 who have been employed as key participants in bringing community-based care to the 60 villages served by the Nohana clinic
• more than 50 patient visits per day at the Nohana clinic
• a contract with the World Food Program to provide food packages consisting of corn meal, beans, cooking oil and a nutritious corn-soy blend to HIV and TB patients and their families.

Steep challenges in the high mountains

The challenge could hardly have been more daunting, both medically and geographically. With the world’s third highest rate of HIV infection, Lesotho has more than 320,000 people living with HIV out of a total population of only 2 million. Only 10 percent of AIDS patients who need antiretroviral drugs are receiving them.

Roughly one-third of Lesotho’s people live in isolated mountain villages, often accessible only on foot or on horseback. They are almost completely cut off from health care but not from the HIV epidemic, driven by poverty that forces nearly one out of three Basotho men to migrate to South Africa for work. For 11 months of the year, they toil in the mines, cut off from their families and living in crowded worker hostels where they are at high risk of infection with HIV, tuberculosis, and other diseases. When they return home for the holidays, all too often they bring deadly diseases with them.

Estimates and testing results suggest that more than 50 percent of adults in mountain areas may be infected with HIV. These same  areas had been largely ignored by efforts to scale up treatment for HIV until the Lesotho government invited PIH and the Clinton HIV/AIDS Initiative to create a model for bringing care to people in the mountains.

From day one in Nohana, PIH has moved not just to scale up HIV testing and treatment but to strengthen health care and health status overall by implementing all “four pillars” of our HIV Equity Initiative. That means embedding HIV treatment within a comprehensive, community-based model of care that: provides primary health care; advances care of tuberculosis (the leading cause of death among HIV patients in Africa); emphasizes women’s health; and improves screening and treatment of sexually transmitted infections.

Building a model of community-based care

When PIH arrived in Nohana, all four pillars needed to be built almost from scratch. Until our arrival, the one-room health center offered limited testing but no treatment for HIV. It had no infectious disease clinic, no waiting room, and a poorly stocked pharmacy the size of a small closet. Despite obvious signs of a major epidemic of tuberculosis, only five patients had been diagnosed and treated for tb during the entire year prior to our arrival.

Now, says Dr. Jonas Rigodon, all that has changed. Dr. Jonas, a Haitian doctor now based full-time in Nohana, reports that, “The infectious disease clinic is functional. We have almost 600 HIV and TB patients enrolled in follow-up. We have increased and trained the staff and we now have stocks of essential medicines.”

Much remains to be done to improve facilities and reach more patients. For example, Jonas and his colleagues still face great difficulties in getting lab results to confirm tuberculosis diagnoses.

“More than 90 percent of sputum results are never sent back to us,” he reported, and x-rays are often so poor they cannot be used. “We need a chest x-ray machine and a lab and lab technician to serve all the PIH sites,” Jonas said.

The list of needs hardly stops there. But the record of accomplishments has kindled confidence that needs will be met, lives will be saved and the model of Nohana can be replicated at other mountain clinics.

Dr. Jonas recounted a striking example from his early days in Nohana:

“One of the village health workers came to me,” he recalled. “She said, ‘I know a patient who is too sick to come to the clinic. Do you think you could go to her house?”

“‘No problem,’ I said.”

“You will have to ride a horse six hours to get there,’” she told me.

“No problem,” I said.
“When we got there, the woman was so weak she could not even sit up in her bed. We started her on treatment that same day. And six weeks later, she was back on her feet and eager to come to the clinic. We helped rent a horse for her and she came.”

As PIH completes its first year in Lesotho, similar stories are now unfolding both in Nohana and at our second site in Bobete.

[posted January 2007]