In-depth: The Treatment Era: ART in Africa
LESOTHO: Not enough staff, poor infrastructure, but ART launched
ARV treatment has just begun at Motebang Hospital in Leribe, Lesotho, but resources are scarce
JOHANNESBURG, 6 December 2004 (IRIN In-Depth) - The office of the Lesotho's HIV/AIDS Directorate, on the 6th floor of an office building in downtown Maseru, the capital, has almost none of the amenities of a modern bureaucracy.
The few computers cannot access the Internet; the bathrooms have no toilet paper, soap, or paper towels. Since this division of the Ministry of Health and Social Welfare was relocated from the 8th floor two months ago, the office has had no telephone line because the government has not paid the bill.
Lesotho, a landlocked kingdom surrounded by South Africa, has one of the highest HIV prevalence rates in the world, with nearly one in three adults living with the virus. But drugs that can delay the progress of the disease are only now becoming available through government-subsidised programmes, exposing a woefully limited public health infrastructure in the process.
"The main problem is manpower," said Mateboho Liphoto, one of only two registered nurses who run the directorate's clinical services department, overseeing all public medical programmes on HIV/AIDS and sexually transmitted infections in this nation of 1.8 million. "We really, really need human resources."
By the end of 2005, Lesotho aims to have 28,000 people on antiretroviral therapy (ART). If successful, the endeavour would cover nearly nine percent of the estimated 320,000 HIV-positive Basotho. But this ambitious plan is still in its infancy.
The first treatment centre to deliver low-cost drugs as part of a national rollout strategy, launched in Maseru in May, is funded almost entirely by pharmaceutical giant Bristol-Myers Squibb. The drug company contributed US $4.5 million to the first three years of the project, on condition that the government takes over the bulk of the costs in 2007.
The Senkatana Centre originally hoped to enrol 400 people in the first year of operation. Yet in just seven months it has put nearly 600 patients on antiretrovirals (ARVs) and is monitoring another 300, who will probably need treatment soon.
"The influx of patients to this clinic has been overwhelming," said Senkatana's project director, Dr Pearl Ntsekhe. "But because of the ever-increasing numbers, it is very hard on our staff - a sort of fatigue is setting in ... the only solution is to add more staff."
This is difficult in much of sub-Saharan Africa, where many trained medical professionals have left in search of higher-paying jobs in the United Kingdom, Australia, the Middle East, and North America.
The government opened the first of its own ARV clinics in November 2004. Two more are scheduled to open early in 2005, with at least another two to follow by the end of the year. Ultimately, the programme plans to open one public ARV distribution centre in each of the nation's 10 districts, located at an established hospital so as to draw on existing staff.
But some officials question whether the government will reach its target of having 5,000 patients on ART nationwide by the end of 2004. "That's essentially impossible," said Dr Limpho Lekona, director of the new ARV treatment clinic at Motebang Hospital in Leribe, 90 km north of Maseru.
The directorate said efforts to reach these targets would likely have a major effect on healthcare workers. Each of the clinics will have a core team of at least one doctor, a nurse, pharmacist, lab technician and professional counsellor. Considering the thousands of potential ARV patients, it's questionable whether the limited staff will be able to handle the demand.
"In these teams, there's only one doctor - there's no doubt they will be worn out," Liphoto said. "In order to achieve this goal, we need more hands."
Mat'enase T'enase, the other clinical services manager in the directorate, said the government had already ordered more than US $830,000 worth of ARV drugs for the launch but, in addition to staff and drugs, other resources are critical to making ART a success.
"Even if we were giving out all the doses, the space and the equipment are also problems," T'enase said. "We don't have the computers to keep track of the data."
In the absence of a countrywide treatment programme, some community members are struggling to address the crisis by providing ad-hoc education, counselling and nutrition services on their own.
"Treatment is not widespread," said Bakoena Bernard, a volunteer with Positive Action, the only network of HIV-positive people in Lesotho.
Access needs to be massively expanded and publicised to save those in immediate need of treatment, Bernard said. Despite government pronouncements, programmes have yet to go beyond the planning stages.
"It has become a political issue because the government is paying lip service, to be viewed by the international community that they are doing something," he said. "But on the ground, the question is whether it gets there or not."
At the directorate, Liphoto said none of Lesotho's 22,000 HIV positive children were currently receiving ARV treatment as part of the national rollout, because the kingdom simply does not have the capacity. "There is only one public-sector paediatrician working in the entire country."