LESOTHO: Testing campaign struggles to get off the ground
Inside a testing tent at the launch of the Know Your Status campaign in Quthing District.
Quthing, 20 October 2006 (IRIN) - Ten months after its official launch, Lesotho's ambitious plan to take the offer of an HIV test to every village and household in the country has yet to get off the ground.
The original goal of the 'Know Your Status' campaign was to give everyone over the age of 12 the option of HIV counselling and testing by the end of 2007, but it has taken months of groundwork to prepare communities, local health centres and volunteer health workers.
Universal testing may not sound like an unrealistic proposition for Lesotho, which has just 1.8 million people, but in the context of a severe health worker shortage and its largely poor, rural population, many of whom can only be reached on foot or by horseback, the obstacles are considerable.
The campaign has received technical support from the World Health Organisation and financial backing from the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as the United Nations Development Programme and the Global Business Coalition on HIV/AIDS, but much of the US$12.5 million needed to carry out testing has yet to be raised.
Even with the finance in place, there are concerns that a sharp increase in patients seeking treatment - the expected result of the testing campaign - could overwhelm Lesotho's already ailing healthcare system.
"The biggest challenge will be whether the health system is able to absorb people adequately for post-test support," said Nthati Lebona, the campaign's newly appointed coordinator.VOLUNTEERS WILL CARRY CAMPAIGN
The key to the success or failure of Know Your Status lies with the volunteers, who will do the testing. So far 720 have been recruited, a long way from the target figure of 3,500. "We're covered for the critical areas, so we'll see how far that takes us. If we can't train 3,500 volunteers, we'll make do with less," said Lebona.
Last week, the southern province of Quthing became the third of Lesotho's 10 administrative areas to launch the testing phase of the campaign with an event in the village of Mphaki, high up in the mountains. Members of the national health department made the four-hour journey from the capital, Maseru, to address an audience consisting mainly of school children and tents were erected for testing.
Those doing the testing had also travelled from Maseru. The volunteers recruited to do the outreach work that is to form the backbone of the campaign, had only begun their 10-day training programme the day before.
"We're still putting the infrastructure in place," said the health department's media officer, Lenka Sello. "We're going slowly to give government the chance to scale up treatment. Except for places in the mountains that have no roads, there should be no place that people have to travel more than two kilometres to get ARVs [antiretroviral drugs]."
According to Lebona, 14,000 people are receiving ARV treatment through the government programme, but the WHO estimates that around 58,000 people need to begin treatment.
"So far, people are quite happy with the campaign because we're bringing service to their door," Lebona said. Testing has not reached any one's door yet, although the two-year awareness campaign that preceded the initiative appears to have convinced more people to visit their local clinics to be tested. Lebona estimates that around 100,000 people have been tested in the past two years.VOLUNTEERS AWAIT FUNDING
Mafeteng District, about 70km south of Maseru, celebrated the launching of its campaign in August, and completed the volunteer training and community mobilisation phases several months ago. According to several volunteers PlusNews spoke to, the only thing preventing them from going out to the villages to begin testing was a lack of funding for transport, tents and rapid testing kits.
"We've been preparing the villages where the clinics are ready to offer treatment," said Qenehelo Sebusi, 25, a volunteer from Mafeteng. The process involves consulting with village chiefs and community members to determine whether they want testing to take place door-to-door or in a centrally located tent. Communities can also choose whether they want the testing to be conducted by local volunteers or, in the interests of confidentiality, by volunteers from elsewhere.
"They keep saying, 'when are you going to start?' because it is now three months since we talked to them, but now the money is not there and we don't know what the problem is," said Sebusi.
Dr Limpho Maile, head of the government's HIV/AIDS directorate, told PlusNews there was enough money for essentials, like test kits and tents, but conceded a shortfall for supporting volunteers with stipends for transport and food.
"We've submitted requests to foreign donors, and the finance ministry is preparing to give us some contingency funding for the stipends," she said. "Most are going to be working in the villages where they live, so they won't need much money for transport but they'll receive a 250 Maluti (US$33) a month stipend."
For now, Sebusi and some of the other volunteers are using this waiting period to practise their counselling and testing skills at Mafeteng Hospital's HIV/AIDS clinic. Most were taking part in the campaign after the experience of losing family members to AIDS, or because of their own HIV-positive status. They did not expect payment, but expressed frustration that they have so far received no support, even in the form of meals.
"We're motivated because we want to help people," said Sebusi, "but we can't help if we're hungry."THE GREAT TESTING DEBATE
Financial and logistical challenges aside, there are those who question the wisdom of the universal testing endeavour. The initiative has helped fuel the ongoing international debate about the most appropriate approach to HIV testing. Most countries in the region still follow a model that puts the onus on individuals to seek out and request an HIV test.
The persistent social stigma associated with HIV has led to an emphasis on confidentiality and extensive pre- and post-test counselling, designed to protect human rights. But increasingly, doctors, experts and activists in the field of HIV are arguing that these special protocols contribute to the "exceptionalisation" of HIV, further stigmatising the disease.
Others, including former US President Bill Clinton, take the view that in a country like Lesotho, where one in four adults are believed to be infected, universal testing is imperative. "The whole idea is to treat this as a public health problem, not as some source of shame or disgrace, and to keep as many people alive as possible," he said in March.
The Know Your Status campaign includes an awareness-raising component to tackle stigma and educate people about HIV before the offer of a test is made. Volunteers are also supposed to provide pre- and post-test counselling, but the line outside the testing tent in Quthing moved too rapidly for the counselling to be anything but perfunctory.
Campaign coordinator Nthati Lebona believes volunteers should determine when counselling is wanted and needed. "Human beings differ, so we should be flexible about counselling. Some might say, 'Just test me.'"
But Matsepo Lepelesana, of Positive Action, the local AIDS group, said a more uniform approach to counselling is needed if it is to be effective. She also argued that simply having ARVs in place does not add up to adequate post-test support. "Before you go onto the ARVs you have to have information, and I have a concern about whether these people, before and after they test, will receive enough information."
How truly voluntary the testing will be is another concern. In a society where village chiefs still command considerable authority, said Lepelesana, their involvement in the campaign may have the effect of making some community members feel obliged to test.
However when the campaign is eventually implemented, it seems certain that international donor agencies and other countries in the region will be following it closely.
Jim Yong Kim, former director of the WHO's HIV/AIDS department, has predicted that the initiative could yield a 80 percent to 90 percent testing uptake, in which case it could be as effective in reducing HIV infections as a moderately effective vaccine. If he is right, it seems likely that other countries will adopt more proactive testing strategies.