The decentralized model of care developed in Scott catchment area covers one 102-bed district hospital and 14 basic, rural health centres, each staffed only by nurses. These nurses are responsible for providing all primary health care and for integrating a full range of HIV/AIDS services, including HIV testing and counselling (HTC), prevention of mother to child transmission (PMTCT) services, TB and HIV care, and antiretroviral therapy, into the package of primary health care offered at the health centre level.
At the start of the programme, approximately 30,000 people were estimated to be living with HIV/AIDS in Scott catchment area. Knowledge of clinical management of HIV was limited and few drugs to treat opportunistic infections were available; ART was not available at all. Building on MSF's previous experience in South Africa [16
], nurses were supported to initiate and manage HIV care and ART at the health centres. Unlike South Africa, the Lesotho health authorities encouraged task shifting to enable all levels of nurses with diagnosing, prescribing and dispensing powers; this model was readily accepted by the MOHSW for replication throughout the country (Table ).
Allocation of HIV and TB tasks for doctors, nurses and lay counsellors at primary health care level
To equip nurses with the skills to meet these new responsibilities, intensive in-service theoretical and practical training was provided on management of HIV-related conditions and ART. This included quarterly "out-of-service" trainings, each lasting one week, which were clinical trainings adapted from the World Health Organization's (WHO's) Integrated Management of Adolescent and Adult Illness (IMAI) [17
Targeted trainings were also provided on the basis of weaknesses identified via pre- and post-test evaluations and in-service support and supervision visits. These covered specific issues, such as drug management, monitoring and evaluation, laboratory investigations, diagnosis of smear-negative TB, DR-TB, infection control, family planning, isoniazid prophylaxis, PMTCT, and paediatric ART. In addition, a number of clinical support tools were developed, including a nurse-oriented guideline for HIV management [18
], an algorithm for the diagnosis of smear-negative TB [19
], and standardised protocols and flowcharts for basic clinic procedures.
Each clinic is staffed by just one or two nurses (often, they are nursing assistants with just two years of training), who provide a full range of primary care activities. Their work is supported by a doctor or an experienced nurse clinician, who visits on a weekly or bi-weekly basis to provide clinical mentorship for nurses on such issues as: the diagnosis and management of complicated HIV-related conditions, antiretroviral (ARV) side effects, and other clinical challenges; referral support for complicated cases; and assistance with general clinic management, including monitoring and evaluation tasks.
Nurse workload is high. An assessment in August 2006 found that nurses were carrying out up to 45 consultations per day, far greater than the WHO recommended maximum of 30 consultations per day (excluding HIV consultations). Acknowledging that the ever-increasing need for ART could not be met due to scarcity of doctors, nurses and other professional health staff, MSF and Scott Hospital established a cadre of HIV/TB lay counsellors to reinforce capacity to deliver HIV and TB services.
In contrast to traditional models of community-based health worker support, these lay counsellors (typically people living openly with HIV/AIDS) are facility based, receive structured training in HIV and TB and counselling, have clear task descriptions, and are compensated for their work, receiving 39 to 55 maloti (US$5-7) per day. As of July 2009, there were a total of 42 facility-based lay counsellors working across the catchment area.
Lay counsellors manage HTC services and provide pre-ART preparatory counselling, and ART and TB treatment adherence support. They also carry out general clinic support tasks, including tracking of patients who are eligible for ART but have not yet been started, and organising ART and TB defaulter tracing. One of the challenges they face, and an important barrier to adherence, is that many Basotho move temporarily or semi-permanently to South Africa in search of work.
Clinic staffers, including counsellors, try to respond to their clients' needs by detailing HIV clinical history in patient-held records, providing two to three month refills, and helping the client's continuity of care by discussing what facilities provide ART care in the area in South Africa to which they are moving.