Baylor College of Medicine Children’s Foundation - Lesotho (Baylor-Lesotho) operates a Center of Excellence (COE) in the capital, Maseru, and five Satellite Centers of Excellence (SCOEs) in the surrounding districts. Baylor-Lesotho staff provide practical hands-on training in HIV, TB, and general child health at the COE, SCOEs and at public health facilities, and other medical expertise and professional training to Ministry of Health (MOH) hospitals and health centers.
Lesotho is small but very mountainous, making travel difficult for people living in remote villages. Thus, while the need for HIV services and education exist, BCMCF-L faces significant challenges in reaching those people. The SCOEs help decentralize health care and serve as a catalyst to build its outreach programs, Teen Clubs and educational efforts.
Baylor-Lesotho plans to expand its psychosocial services for all ages, especially adolescents. By 2014, Teen Club had grown to include over 900 HIV-positive adolescents. Caring Fathers, a support group for men who have HIV-infected family members, encourages men to get tested, access treatment, and support their families. Unique among the BIPAI network, Lesotho also provides comprehensive medical evaluation of children released for adoption from orphanages.
BIPAI’s Global Health Corps (GHC) physicians are based at the COE, and work with a strong local team to provide direct patient care to HIV-exposed and infected children and their families. They also provide medical education to health professionals through didactic lectures and side-by-side mentoring at the COE and other health centers and hospitals. Those interested in inpatient medicine rotate through pediatric wards at the nearby national referral hospital. They can contribute to local policy by serving on relevant technical advisory committees to the MOH. Finally, GHC physicians interested in research and quality improvement efforts are welcome to suggest new programmatic endeavors.
Year founded: 2005
Services: tuberculosis, HIV/AIDS
Total patients in care: 4,711
Health professional trained: 218
Total budget: 4.7 million
Baylor-Lesotho takes a holistic approach to HIV care and treatment. Although most of our patients are HIV-infected children, we also serve their HIV-infected family members. Service provided include Prevention of Mother-to-Child Transmission of HIV (PMTCT), early infant diagnosis, antiretroviral therapy (ART), adherence counseling, treatment literacy, TB diagnosis and treatment, nutritional care and immunizations.
Epidemiologic Data and Clinic Statistics
Below is a brief overview of the HIV/AIDS epidemic in Lesotho and the scope of our work.
HIV/AIDS in Lesotho
Lesotho has the second highest HIV prevalence in the world at 23.1%. As of 2012, there were 360,000 persons living with HIV (PLHIV). ART coverage is estimated at 57% for adults and at 26% for children (Lesotho National HIV and AIDS Strategic Plan, September 2013). 72% of adults and children remain in treatment 12 months after initiation of ART. PMTCT coverage has increased from 12% in 2005 to 58% in 2012. New HIV infections among children have decreased from 6,100 in 2001 to 3,700 in 2012. Although there have been recent gains in reducing new child infections, much work remains to be done in reversing the HIV/AIDS epidemic in Lesotho. [Source for all unmarked statistics: UNAIDS 2012]
Maseru COE Statistics
Since opening in 2005, over 9,400 patients have been enrolled at the COE. As of January 2015, our COE has over 3,100 active patients, of whom 500 are HIV-exposed infants. 92% of the HIV-infected children, adolescents and adults are receiving ART. Annually, HIV testing and counseling is provided to almost 2,000 individuals.
Satellite COEs Statistics
As of January 2015, our SCOEs have a total of over 1,100 active patients. As in Maseru, almost all patients are on ART. Since our SCOEs began operations, over 1,500 patients have been enrolled. Each year, nearly 3,000 individuals are tested for HIV at the SCOEs.
Clinical Care for Children and Adults
Baylor-Lesotho takes a holistic approach to HIV care and treatment. Although most of our patients are HIV-infected children, we also serve their HIV-infected family members.
Prevention of mother-to-child transmission of HIV infection is the cornerstone in the fight against pediatric HIV. Baylor-Lesotho continues to support the Lesotho Ministry of Health in providing all HIV-infected pregnant and breastfeeding women ART treatment for life. This new strategy for PMTCT benefits the woman, her child and her family.
Early Infant Diagnosis
Without treatment, one-third of HIV positive infants will die before their first birthday and one-half will die before their second birthday [Source: UNAIDS 2013]. Early infant diagnosis is essential for reducing infant mortality. Baylor-Lesotho proactively tests exposed infants using HIV DNA PCR technology in collaboration with Lesotho’s national reference laboratory.
Antiretroviral Therapy (ART)
ART is the cornerstone of HIV treatment, and Baylor-Lesotho provides life-saving therapy to children of all ages. Monitoring of treatment success and potential medication side effects is provided on a scheduled basis. Baylor-Lesotho clinicians are local experts in pediatric ART care and often consult on complicated patients receiving care at other facilities. Baylor-Lesotho also provides 2nd-line and 3rd-line treatment options for those who have failed therapy, in consultation with the Ministry of Health ART Advisory Committee.
Consistent adherence to ART is essential for treatment success and prevention of unnecessary morbidity and mortality. Before initiation of ART, patients receive thorough adherence counseling to prepare them for their treatment regimens. Baylor-Lesotho always has a social worker on duty for ongoing adherence counseling and psychosocial support based on referrals from our health professionals.
HIV can be an overwhelming diagnosis for children and family members alike. Baylor-Lesotho has full-time treatment literacy staff to support our patients and their caregivers in understanding how to take their medications. They also help parents gradually disclose their children’s HIV status to them as they grow and become better able to understand their diagnosis and treatment. Visual aids comparing CD4 cells to soldiers keeping them healthy are used to help children understand why their medication is important.
TB Diagnosis and Treatment
Since HIV and TB are inextricably linked, Baylor-Lesotho actively screens patients for TB and provides prophylaxis. Infection control procedures have been strengthened and patients receive a daily briefing on TB prevention and diagnosis. Baylor-Lesotho provides TB treatment for children regardless of their HIV status. Recent efforts have improved the care of HIV-uninfected children suffering from tuberculosis and many children are referred to the COE and SCOEs for this care.
Baylor-Lesotho has a full-time nutritionist who provides consultations to parents whose children have been diagnosed as malnourished. Therapeutic foods are provided to children with severe malnutrition through Ministry of Health programs. We have also partnered with other organizations to support the establishment of Nutrition Corners across Lesotho where health professionals educate mothers on proper nutrition for infants and young children monthly. Sessions are interactive with a hands-on demonstration of nutritious food preparation using readily available local ingredients and gardening. Through a generous donation from AIDS Orphan Care, children with mild malnutrition are provided with peanut butter to improve their diet and nutritional status. Infants and children are also provided with routine vitamin A supplementation and regular de-worming – national strategies to improve nutritional status.
The COE is proud to participate in the Lesotho Expanded Program for Immunizations (EPI) and provides routine childhood vaccines for our HIV-exposed and infected infants and young children.
Specialized Adolescent Clinic
Since May 2012, youth aged 14-20 years have received services from a dedicated team of professionals at the Baylor-Lesotho Adolescent Clinic in Queen ‘Mamohato Memorial Hospital. Feedback from the adolescents has been quite positive. They enjoy having their own space and freedom to speak on relevant topics. We envision the Adolescent Clinic to serve as a natural transition to adult care services.
Also, deeper relationships are built as the adolescents repeatedly interact with a smaller team of health care providers. We have been able to better identify and assist those who are struggling to take their medications correctly. A nutritionist and psychologists hold weekly clinics to provide additional services. Two peer educators have also been identified and trained to address the unique needs of adolescents living with HIV.
Adolescents living with HIV (ALHIV) have unique health needs. Recent research has demonstrated that adolescent-friendly services that foster peer support help ALHIV effectively transition to adulthood (Pettitt et al. 2013). Baylor-Lesotho provides adolescents with a specialized program of care and treatment to help ensure successful treatment outcomes during this challenging life stage.
Baylor-Lesotho also has full-time psychological staff to consult patients presenting with mental health problems or concerns. Some common referrals are related to depression, learning disabilities and behavior problems. Children who have been victims of sexual abuse are often referred for counseling from nearby facilities as few facilities have full-time psychologists.
Baylor-Lesotho believes in holistic HIV treatment which cares for the whole person. This necessitates programs which address the psychosocial needs of our child and adult patients. Currently we run three major psychosocial support programs for various types of patients:
Teen Club supports HIV positive youth aged 11-18 years old and meets monthly at our COE and SCOEs. The mission of Teen Club is to empower HIV-positive adolescents to build positive relationships, improve their self-esteem and acquire life skills. Teen Club strives to ensure improved clinical and mental health outcomes for our adolescents as well as a healthy transition into young adulthood through peer mentorship, adult role modeling and structured activities. Currently, there are over 900 active Teen Club members across Lesotho.
In 2012, a Wise Ones group for youth 18-24 years old was formed at our COE to provide continued life skills support for youth that have graduated Teen Club and remain patients of Baylor. The Wise Ones meet once a month to share in educational and recreational activities and attend Teen Clubs to facilitate activities and to serve as positive role models and mentors for the younger teens. Plans are being developed to begin similar youth groups in other sites.
Caring Fathers is a support group for men who have HIV-infected family members. The program encourages men to get tested, to access treatment and to support their families. Caring Fathers meets monthly at the COE and is led by one of our social workers.
Training & Education
Baylor-Lesotho conducts clinically relevant operational research, assisting in the care of children at the COE, SCOEs and throughout Lesotho. Our research into outcomes and best practices supports our mission to continually improve and thoroughly understand what works best in caring for children with HIV, TB and malnutrition in our country’s unique setting. Results from any research conducted are used to improve care at the COE, throughout Lesotho and in other countries.
Ongoing Medical Audit
As Lesotho looks forward to achieving its goals regarding the HIV pandemic, it is of crucial importance to look critically back at our achievements—including in the clinical arena—and to use any lessons learned in refining future plans, especially in regards to the care of children infected or affected by HIV. Baylor-Lesotho is currently conducting a comprehensive medical audit of clinical and monitoring and evaluation records maintained at the COE and SCOEs between December 2005 and December 2013.
The main purpose of the audit is to learn from our experience in managing children with HIV with a view to improve the care being provided and to inform health policy as it relates to the care of children in Lesotho. A secondary objective is to share any appropriate findings with the wider health and medical fraternity.
Past and Ongoing Research
All Baylor-Lesotho research studies are approved by the Research Ethics Committee of the Ministry of Health, in-country Institutional Review Board (IRB) and Baylor College of Medicine IRB. Examples of past and ongoing research topics include:
Evaluation of the Lesotho Emergency Triage Assessment and Treatment (ETAT) Training Project
A Prospective Evaluation of Clinical Outcomes and Determining Baseline Factors of Clinical Outcomes of HAART in the Pediatric Population of BIPAI Children’s Centers of Excellence in Africa
A Prospective Comparison of Adherence to HAART amongst Adolescent Patients of the BIPAI Children’s Centre of Excellence before and after Attendance at Recreational Therapy Camp
Needs Assessment for Development of a General Pediatrics Nurse Training Curriculum in Lesotho
A Retrospective study to Evaluate the Effects of Isoniazid Preventative Therapy on Anemia in HIV-infected Children
Comparison of the Effectiveness of using a single drug Zidovudine versus a 3-drug combination therapy for Prevention of Mother-to-Child-Transmission of HIV at Baylor College of Medicine Children’s Foundation Clinical Center of Excellence-Lesotho
Medical School Partnership
In 2014, Lesotho’s Ministry of Health founded its first medical school. Baylor-Lesotho has been requested to support the education of medical students, specifically in pediatrics. We are grateful for the opportunity to support the professional development of future Basotho physicians and pediatricians. More information to come as this partnership develops.
Patient Home Visits
Patients who miss clinic appointments and fail to return for care are traced using a combination of phone calls and physical visits to their homes by a team of nurses, social workers and trained volunteers. Over the last year, nearly 2,000 patients were called or visited to ensure retention in care. This resulted in dramatic reductions in patients who are lost from care and therefore receive inadequate treatment. The volunteers also visit households affected by TB to find additional cases.