Cost and cost-effectiveness of switching from d4T or AZT to a TDF-based first-line regimen in a resource-limited setting in rural Lesotho

Article approval pendingLatest World Health Organization guidelines recommend shifting away from Stavudine (d4T)-based regimens due to severe side effects. However, widespread replacement of d4T by Tenofovir (TDF) or Zidovudine (AZT) is hampered by cost concerns

Early initiation of antiretroviral therapy and associated reduction in mortality, morbidity and defaulting in a nurse-managed, community cohort in Lesotho.

INTRODUCTION: The latest WHO guidelines recommend initiating antiretroviral therapy (ART) at CD4 cell counts less than 350 cells/μl. However, donors and national governments are reluctant to support implementation owing to uncertainty regarding feasibility and relative benefit. Lesotho has supported earlier initiation since 2008. We assessed outcomes comparing early (CD4 cell counts >200 cells/μl) and late (CD4 cell counts ≤200 cells/μl) initiation. METHODS: We describe survival probability among patients initiating ART at CD4 cell counts 200 or less and more than 200 cells/μl and assess associations between baseline CD4 cell counts and mortality, morbidity, loss to follow-up and hospitalization using Cox regression adjusting for confounders identified a priori. RESULTS: Our analysis included 1177 patients; median age was 38 years and the majority (67%) were women. Median time on ART for the overall cohort was 506 days (interquartile range 396-608). Five hundred and thirty eight patients initiated ART at a CD4 cell count 200 cells/μl or less (interquartile range 54-160) and 639 patients initiated at CD4 cell count more than 200 cells/μl (interquartile range 238-321). In multivariate analysis, we found that patients initiating at CD4 cell count more than 200 cells/μl were 68% less likely to die (adjusted hazard ratio 0.32, 95% confidence interval 0.20-0.50), and 39% less likely to be lost to follow-up (adjusted hazard ratio 0.61, 95% confidence interval 0.43-0.87). Initiating ART at CD4 cell count more than 200 cells/μl was also associated with a 27% reduction in the rate of incident morbidity (adjusted hazard ratio 0.73, 95% confidence interval 0.65-0.82) and a 63% decreased rate of hospitalization (adjusted hazard ratio 0.37, 95% confidence interval 0.19-0.73). CONCLUSION: Earlier initiation is feasible in a low resource, high HIV prevalence setting, and provides important benefits in terms of reduced mortality, morbidity, retention and hospitalization. Donors should fully support the implementation of the latest WHO recommendations

Evaluation of strategies instituted to improve the tuberculosis control program within Scott Hospital Health Service Area, Lesotho

Thesis (M Med(Family Medicine))--University of Limpopo (Medunsa Campus), 2010.Background: In spite of the substantial progress made in the development and implementation of many strategies necessary for effective tuberculosis control, the disease continues to be the leading cause of death, and in Africa, because of the expanding HIV epidemic, there has been an increase of HIV associated TB. In 2005 African health ministers declared TB a regional emergency. Although TB treatment is free and Lesotho has 100% DOTS coverage, the country still reported an incidence of 485 per 100,000 population (2005) and a treatment success of 74%, which is still lower than 85% WHO target. Objective: This six-month study at Scott Hospital Health Service area in Lesotho was undertaken to assess the outcome measures of strategies instituted to improve the tuberculosis control programme and determine the effect on TB treatment outcome indicators and TB/HIV integration. xi Methodology: The study design was a quantitative, descriptive study. The principal researcher and a research assistant used a questionnaire to collect data from the outpatient, TB suspect and treatment registers. Study population and sample: The subjects of the study were all adult new sputum- smear positive TB patients enrolled and registered in the Scott Hospital Health Service area TB register from 1st January to 30 June 2006. Results and discussion: A total of 100 new sputum smear positive adult TB patients presenting at Scott Hospital during the research period formed the sample group of this study. This included 47 female and 53 male patients. Their ages ranged from 18 years to 84 years with the mean age of 42 years. Majority 52 (52%) were in the age group 20-39 years, followed by 27 (27%) in age group 40-59 years and 19 (19%) in the age group 60-79 years. There was a high TB/HIV co-infection of 40 (81.6%) among the 49 (49%) who accepted HIV counseling and testing. Active screening of patients for TB resulted in 378 (86.3%) of the 438 TB suspects having their sputa tested. Of these, 100 (26.5%) were new sputum smear positive. Good xii adherence and treatment supervision resulted in sputum conversion rate of 89 (89%). Rigorous implementation of the DOTS strategy showed increased treatment outcomes: cure rate of 76 (76%) and treatment success of 85 (85%). These results were similar to findings of other studies carried out in Cambodia, Tanzania and Rwanda to assess TB programme performance following introduction of improvements. Conclusion: This study demonstrates that implementation of activities consistent with new stop TB DOTS strategy to improve TB control is possible in a rural setting and leads to improvement in TB case detection and treatment success and a decrease in both defaulter and death rates

The food and nutrition security potential of smallholder dairy farming in rural Eastern Cape, and evaluation of milk handling and hygiene practices.

Master of Science in Food Security. University of KwaZulu-Natal, Pietermaritzburg, 2016.Milk is a leading nutritive food source. Rural smallholder dairy farmers in South Africa have the potential to contribute significantly to milk supply for own consumption as well as to the lucrative formal urban markets, which would contribute to enhanced rural household livelihood options and improve food and nutrition security of the country. However, milk is highly susceptible to microbial contamination and as such strict hygiene and quality management are required to ensure that the product is of acceptable quality and safety. The formal urban markets particularly set high standards of milk quality and safety. On the other hand, rural smallholder dairy farmers are generally resource poor- they rely heavily on Indigenous Knowledge Systems (IKS) in their dairy practices. The IKS-based dairy practices would probably not be adequate to achieve quality and safety standards of milk demanded by the formal urban markets, which would severely restrict the rural smallholder farmers accessing these lucrative markets. Whilst some studies have been conducted in other Sub-Saharan African countries on the dairy practices of rural smallholder farmers and the impact of the practices on milk quality and safety, it seems that similar studies have not been conducted in South Africa. The aim of the current study was to investigate milk utilisation patterns and assess dairy practices, including animal husbandry and milk handling and hygiene practices of rural smallholder dairy farmers of the Matatiele Local Municipality in the Eastern Cape Province of South Africa. The potential impact of these practices on milk quality and safety was also investigated. A sample of 150 smallholder dairy farmers were selected from rural areas of Matatiele by simple random sampling and used to determine whether their dairy practices where informed by IKS. The perceptions of the farmers about the importance of milk quality and safety in relation to their dairy practices were also explored. The sampled farmers were interviewed using a pre-tested questionnaire on various aspects of dairy practices, namely the farm facilities; animal husbandry; milking practices; and the sources of the knowledge used to inform their practices. Focus group discussions (FGDs) were conducted to explore the perceptions of the farmers about milk quality and safety and transect walks were done to observe the dairy environment. The study revealed that milk was an important protein source that was commonly consumed by 94% the farmers. The majority of the farmers predominantly used IKS in their dairy practices. The farmers housed their cows in kraals, milked by hand in the kraals, and the milk produced ii was stored at room temperature. However, some of the IKS-based practices were in line with the recommended modern agricultural practices. The IKS-based practices were, however, limited with respect to cattle husbandry and hygiene standards. Milk storage was a major challenge due to lack of refrigerators. The majority of the farmers had the perception that milk quality and safety was important, whilst the perception of 17 % of the sampled farmers was that changes that occurred in milk were due to natural fermentation and as such would not impact negatively on milk safety. There is a need to interface IKS-based agricultural practices with the modern science-based agricultural practices in order to address the limitations of the IKS-based practices as well as facilitate the adoption of the recommended modern science-based practices by rural farmers. The study further investigated farmers’ knowledge and awareness of dairy hygiene and quality management through questionnaires, FGDs and direct observation of the milking process. The microbiological quality and safety of the milk was assessed by analysing total plate and coliform counts of milk samples collected from 19 farmers. The questionnaires revealed that the hygiene practices of the farmers were quite in line with the recommended modern science-based practices, although there were few exceptions. The farmers had good knowledge of personal and equipment hygiene, but had poor knowledge of environmental hygiene. The milk was consumed raw and the study participants reported that milk was often contaminated with foreign objects such as grass, dung, and soil. This would impact negatively on milk quality and safety and ultimately the food and nutrition security of the households. Results of microbiological analysis showed that 79% of the samples collected had a Total Plate Count of 8.8 x 105 to 3.3 x 1010 cfu/ml; the coliform counts (2.0 x 101 to 1.6 x 104) 84% of the milk samples exceeded the legal limit (1.0 x 101 cfu/ml); and 57.9% of the samples tested positive for faecal E. coli. These results indicate that the quality and safety of the milk samples was poor. The study findings indicate that smallholder dairy farming is an essential source of rural household livelihoods- it produces milk for household consumption and income. The milk produced is well utilised by the rural communities of the Matatiele Local Municipality; it is used as the main source of protein, especially for children. The farmers aspire to access formal markets, however; they predominately use IKS-based dairy practices, which significantly reduces the ability to achieve the standards of milk quality and safety set by the formal markets. The farmers face serious challenges of limited resources, including finance, quality dairy iii facilities and refrigeration. This seriously limits their ability to achieve acceptable standards of quality and safety, especially the high standards set by the formal markets. There is a need to provide support to these farmers; one critical and essential support area is capacity building, through training of the rural dairy farmers to interphase IKS with modern science in their practices, to improve milk quality and safety. Provision of basic facilities such as taps to increase access to clean and safe water would be also helpful. The provision of cold storage facilities accessible to smallholder dairy farmers would also be helpful in assisting them to maintain microbiological safety

Antiretroviral treatment outcomes from a nurse-driven, community-supported HIV/AIDS treatment programme in rural Lesotho: observational cohort assessment at two years

ABSTRACT: INTRODUCTION: Lesotho has the third highest HIV prevalence in the world (an adult prevalence of 23.2%). Despite a lack of resources for health, the country has implemented state-of-the-art antiretroviral treatment guidelines, including early initiation of treatment (<350 cells/mm3), tenofovir in first line, and nurse-initiated and managed HIV care, including antiretroviral therapy (ART), at primary health care level. PROGRAMME APPROACH: We describe two-year outcomes of a decentralized HIV/AIDS care programme run by Doctors Without Borders/Médecins Sans Frontières, the Ministry of Health and Social Welfare, and the Christian Health Association of Lesotho in Scott catchment area, a rural health zone covering 14 clinics and one district hospital. Outcome data are described through a retrospective cohort analysis of adults and children initiated on ART between 2006 and 2008. DISCUSSION AND EVALUATION: Overall, 13,243 people have been enrolled in HIV care (5% children), and 5376 initiated on ART (6.5% children), 80% at primary care level. Between 2006 and 2008, annual enrolment more than doubled for adults and children, with no major external increase in human resources. The proportion of adults arriving sick (CD4 <50 cells/mm3) decreased from 22.2% in 2006 to 11.9% in 2008. Twelve-month outcomes are satisfactory in terms of mortality (11% for adults; 9% for children) and loss to follow up (8.8%). At 12 months, 80% of adults and 89% of children were alive and in care, meaning they were still taking their treatment; at 24 months, 77% of adults remained in care. CONCLUSION: Despite major resource constraints, Lesotho is comparing favourably with its better resourced neighbour, using the latest international ART recommendations. The successful two-year outcomes are further evidence that HIV/AIDS care and treatment can be provided effectively at the primary care level. The programme highlights how improving HIV care strengthened the primary health care system, and validates several critical areas for task shifting that are being considered by other countries in the region, including nurse-driven ART for adults and children, and lay counsellor-supported testing and counselling, adherence and case management

Renal Safety of a Tenofovir-Containing First Line Regimen: Experience from an Antiretroviral Cohort in Rural Lesotho

Current guidelines contraindicate TDF use when creatinine clearance (CrCl) falls below 50 ml/min. We report prevalence of abnormal renal function at baseline and factors associated with abnormal renal function from a community cohort in Lesotho

Trends in Loss to Follow-Up among Migrant Workers on Antiretroviral Therapy in a Community Cohort in Lesotho

BACKGROUND: The provision of antiretroviral therapy (ART) to migrant populations raises particular challenges with respect to ensuring adequate treatment support, adherence, and retention in care. We assessed rates of loss to follow-up for migrant workers compared with non-migrant workers in a routine treatment programme in Morjia, Lesotho. DESIGN: All adult patients (≥18 years) initiating ART between January 1, 2008, and December 31, 2008, and followed up until the end of 2009, were included in the study. We described rates of loss to follow-up according to migrant status by Kaplan-Meier estimates, and used Poisson regression to model associations between migrant status and loss to follow-up controlling for potential confounders identified a priori. RESULTS: Our cohort comprised 1185 people, among whom 12% (148) were migrant workers. Among the migrant workers, median age was 36.1 (29.6-45.9) and the majority (55%) were male. We found no statistically significant differences between baseline characteristics and migrant status. Rates of lost to follow up were similar between migrants and non-migrants in the first 3 months but differences increased thereafter. Between 3 and 6 months after initiating antiretroviral therapy, migrants had a 2.78-fold increased rate of defaulting (95%CI 1.15-6.73); between 6 and 12 months the rate was 2.36 times greater (95%CI 1.18-4.73), whereas after 1 year the rate was 6.69 times greater (95%CI 3.18-14.09). CONCLUSIONS: Our study highlights the need for programme implementers to take into account the specific challenges that may influence continuity of antiretroviral treatment and care for migrant populations

Educational needs and assets of home-based caregivers for home-bound chronic patients: a case study

Thesis (M.A. Education (Community and Continuing Education)) -- University of Limpopo, 2015This report describes the research conducted at Kgotlelelang Basadi Home-based Care centre, in the Capricorn District Limpopo Province of South Africa. The centre serves four villages: Ngwanamago, Makata, Matobole and Thaba. Statement of the problem It seems the home-based caregivers of chronic patients at Kgotlelelang Basadi HBC centre do not have the necessary qualifications, knowledge, skills, and health care and protective resources such as gloves, thermometers and masks. It looks like the homebased caregivers are not adequately and continuously trained as there are always new discoveries and developments with regard to the treatment of diseases. It apprears they perform their duties without sufficient support by relevant institutions like clinics and hospitals. Furthermore, it appears the home-based caregivers are not recognised, and are also undermined. The aim of the study is to explore the educational needs and assets of home-based caregivers for homebound chronic patients at Kgotlelelang Basadi Home-based Care centre. After establishing the educational needs and assets of home-based caregivers I recommended the formulation of possible relevant educational programmes. In an attempt to achieve the said aims, the following research questions were formulated and put forward in chapter 1. Objectives To establish the existing qualifications of home-based caregivers for home-bound chronic patients at Kgotlelelang Basadi HBC Centre. To determine the relevancy of the existing educational programmes of home-based caregivers for home-bound chronic patients. To contribute towards formulating relevant educational programmes of home-based caregivers for home-bound chronic patients

Revision of the regional maximum flood calculation method for Lesotho

Thesis (MEng) -- Stellenbosch University, 2014.ENGLISH ABSTRACT: The Francou and Rodier (1967) empirical approach uses the original concept of envelope curves for the definition of the regional maximum flood (RMF). Kovacs (1980) adopted the Francou and Rodier empirical flood calculation method and applied it to 355 catchments in South Africa. He revised his study in 1988 to also include the southern portions of the Southern Africa subcontinent. No method other than the Francou and Rodier empirical flood approach in the reviewed literature was found to be suitable for the purpose of this study. Therefore the Francou and Rodier empirical approach, as applied by Kovacs in 1988, was reapplied and used in this study to update the RMF for Lesotho. Maximum recorded flood peaks were derived from annual maximum time series and an up to date catalogue of flood peaks for 29 catchments was compiled for Lesotho. The maximum recorded flood peaks were then plotted on the logarithmic scale against their corresponding catchment areas. There are 3 major river systems that divide Lesotho into hydrologically homogenous basins. Envelope curves were drawn on the upper bound of the cloud of plotted points for these 3 river basins. These envelope curves represent the maximum flood peaks that can reasonably be expected to occur within the respective river basins in Lesotho.AFRIKAANSE OPSOMMING: Francou en Rodier (1967) se empiriese benadering maak gebruik van die oorspronklike konsep van boonste limiet kurwes vir die definisie van die streeks maksimum vloed (SMV). Kovacs (1980) het die Francou en Rodier empiriese vloed berekening metode toegepas op 355 opvanggebiede in Suid-Afrika. Hy hersien sy studie in 1988 om ook die suidelike gedeeltes van die Suider-Afrikaanse subkontinent in te sluit. Geen ander metode as die Francou en Rodier empiriese vloed benadering is in die literatuur gevind wat as geskik aanvaar kan word vir die doel van hierdie studie nie. Daarom is die Francou en Rodier empiriese benadering, soos toegepas deur Kovacs in 1988, weer in hierdie studie toegepas en gebruik om die SMV metode vir Lesotho op te dateer. Maksimum aangetekende vloedpieke is verkry vanuit jaarlikse maksimum tyd-reekse en ʼn opgedateerde katalogus van vloedpieke vir 29 opvanggebiede saamgestel vir Lesotho. Die maksimum aangetekende vloedpieke is grafies aangetoon op logaritmiese skaal teenoor hul opvanggebiede. Daar is 3 groot rivierstelsels wat Lesotho in hidrologiese homogene gebiede verdeel. Boonste limiet kurwes is opgestel om die boonste grens van die gestipte punte vir hierdie 3 gebiede aan te toon. Hierdie krommes verteenwoordig die maksimum vloedpieke wat redelikerwys verwag kan word om binne die onderskeie rivierstelsels in Lesotho voor te kan kom