N/A

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 08 - HBHC Care: Adult Care and Support

Total Planned Funding for Program Budget Code: $733,000

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

OVERVIEW

Lesotho has made significant progress in the area of care, treatment and support in the past few years, however large gaps in

service delivery are still a problem. ART is available in only about half the clinical facilities in the country. Problems with logistics

and transportation of blood samples are still a major problem. Stock-outs of medicines and supplies are a concern everywhere,

and patients often have difficulty reaching health clinics that provide ART. A lack of qualified practitioners still slows the rollout

efforts. Using Global Fund Round 2 and 5 grants, GOL has rolled out ART, which is now available in even some remote parts of

the country. It is estimated that $US 6.8 million was spent on treatment, care and support in the year 2006-07. To support rapid

ART scale-up, GOL instituted a 2% allocation of line Ministry budgets for HIV/AIDS scale up nationwide and directed these funds

to the NAC.

The first ART site in Lesotho was established in 2002 in the capital district of Maseru. In 2004, GoL, with support from WHO,

adopted a scale up plan to decentralize ART service delivery. ART services are now available in a total of 104 out of 205 sites,

including hospitals, health centers and private practitioners. Following a 2007 revision of its ART guidelines, GoL now

recommends that people with a CD4 count below 350 are eligible for treatment, whereas previously ART was recommended

when the CD4 count was below 200. In 2005, 77,986 men and women in Lesotho were in need of ART (UNAIDS 2007), but only

8,000 people had access to ART (10.2%). Coverage has since risen to 39%, with 31,700 people receiving ART as of June 2008

(GFCU 2008). Adult women make up just over 2/3 of those accessing treatment whereas females under the age of 15 make up

half of the children on treatment. In addition, in June 2008, nearly 138,000 people were receiving community home-based care

support (GFCU 2008) and in March 2007, 49,192 people were enrolled on chronic care (MOHSW 2007). MOHSW 2011 goals are

to have 100% of all health center accredited in providing ART services and 60% of eligible people enrolled in ART.

Adult ART service provision in Lesotho is mainly supported by WHO, UNICEF, Canadian NGO OHAfrica, Partners in Health,

MSF, and other NGOs. These organizations, along with MOHSW implement all the ART services in Lesotho including

procurement and distribution of drugs, TA for the development of guidelines and policy and the training of clinicians. MCC

recently entered into force in September 2008, and will build and/or renovate clinics integrating ART clinics with Out Patient

Departments (OPD), hospitals and lab facilities and facilitate training to health staff. WFP is currently providing nutritional support

to approximately 5,510 households infected with and affected with HIV with a total of about 25,158 beneficiaries. The food support

is distributed via health centers once a month.

CURRENT USG PROGRAM

Given the limited funding of the PEPFAR/Lesotho program, the strong performance of the Round 2 and 5 Global Fund grants, and

the support GOL has received from other international organizations, PEPFAR/Lesotho has focused on a number of issues

related to and supporting adult care and treatment which are described in the following program area narratives (PMTCT,

pediatrics, labs, supply chain management). The PEPFAR program provides support for adult care and treatment within the

context of PMTCT-Plus activities by partners ICAP and EGPAF. The PMTCT-Plus program is further articulated in the PMTCT

program area narrative. PEPFAR also carries out care and support activities with LDF through DOD, and works to build health

care workers capacity in collaboration with other PEPFAR funded partners such as MSH and the Southern Africa Human Capacity

Development (SA¬HCD) Coalition (see OHSS narrative).

At the national level, ICAP and EGPAF support MOHSW in strategic planning and the development of PMTCT care and treatment

systems, policies and guidelines, including pediatric AIDS. In FY 2007, changes were initiated in PMTCT policies, including

provider-initiated counseling and testing and dispensation of NVP prophylaxis to HIV-positive pregnant women at the first ANC

visit. Partners supporting PMTCT services in a total of 48 sites added 5,588 individuals to ART; 9,421 individuals are currently

receiving ART at these sites.

The Makoanyane Military Hospital, with support from DoD has been providing palliative care to the military personnel since the

early 1980s. Patients are seen at their own homes through hospital initiated home based care and the health team provides

holistic care and terminal care for its clients, this includes providing spiritual care and psychosocial support to clients and their

families. Patients will also be seen by the Mobile Clinic at the Lesotho Defense Force (LDF) Barracks throughout the country and

at communities nearby the bases and selected other community sites.

USG FY 2009 SUPPORT

At this time, PEPFAR/Lesotho plans to continue providing PMTCT-Plus services in FY 2009, through its implementing partners

EGPAF and ICAP, while developing human capacity within MOHSW and CHAL to improve program quality. As central

agreements with both EGPAF and ICAP will be ending in 2010, PFPFAR/Lesotho plans to provide 6 months of FY 2009 funding

to each, to ensure a smooth transition between programs. PEPFAR/Lesotho will solicit for a new PMTCT partner who will assume

responsibility for current EGPAF and ICAP sites and patient loads, and continue provision of PMTCT-Plus services, including ART

and adult care. PEPFAR/Lesotho feels that the PMTCT program will be enhanced by one strong leader in this important program

area. With transition funding, both EGPAF and ICAP plan to support ART provision within MCH clinics in keeping with the new

MOHSW guidelines and based on the successful pilot of this approach at Queen Elizabeth II Hospital. Both partners will focus on

the provision of comprehensive support to sites, including: facilitating immediate provision of ARV prophylaxis for HIV-positive

pregnant women; staging HIV-positive pregnant women within the maternal and child health (MCH) services, facilitating CD4

testing, providing STI screening and syndromic management, and making timely referrals for treatment for HIV+ eligible pregnant

women. In addition, partners will provide a more complex course of ARV prophylaxis to the HIV+ pregnant women not eligible for

HAART and for all exposed infants, including treatment of opportunistic infections (OIs) and screening and referrals for TB. Both

partners will also continue to develop their family-centered approach to care, with the goal of increasing uptake of ART and care

services for male partners and family members of mothers receiving PMTCT services.

PEPFAR/Lesotho also will solicit for a new partner to strengthen community-based care and facilitate linkages between

community and facility care and treatment. Evidence suggests that many patients who are ineligible for ART are lost to follow-up.

Even those patients that are receiving ART or facility-based clinical care services are not always linked to community services.

We anticipate engaging a partner that is able to bridge this gap and link patients at facilities to community and home-based care

services, and vice versa.

In early 2009, PEPFAR/Lesotho plans to have members of the Adult ART and Care and Support TWGs at headquarters conduct

an assessment of the national Lesotho ART program. Based on that assessment, we will determine how PEPFAR will engage

further in the treatment sector. Given that the majority of ART is being managed by MOHSW through other funding sources,

either through provision of services or support, PEPFAR is eager to identify critical gaps that we could fill.

LEVERAGING AND WRAPAROUNDS

The USG is committed to the synergistic benefits resulting by collaborating with other organizations working in the areas of

PMTCT, ART, and care. PEPFAR‘s PMTCT-plus partners work in concert with Baylor College to refer HIV-positive pediatric

patients for clinical care and ART monitoring. USG sits on the national PMTCT TWG and works with PMTCT partners to ensure

linkages with other adult-care service providers. As the MCC Compact rolls out, opportunities have begun to present themselves

for a wide range of training and human capacity development at the outpatient departments and community health centers

throughout Lesotho.

PROPOSED COMPACT EXPANSION

The expansion of Adult Treatment and support services has occurred primarily through our PMTCT partners. As

PEPFAR/Lesotho moves forward to negotiate a Partnership Compact with GOL, we anticipate further strengthening Adult Care

and Support activities mainly through human resource development activities. To determine how best to assist the GOL in

achieving its goals of improved chronic care (including ART supplies and services), increased psychosocial support, strengthened

home-based and palliative care, PEFPAR will be conducting a thorough assessment of this program area, the results of which will

be taken into account during Compact development.

procurement and distribution of drugs, TA for the development of guidelines and policy and the training of clinicians. MCC recentl

Table 3.3.08: