title: The uncertain future of lay counsellors: continuation of HIV services in Lesotho under pressure.
abstract: Between 2006 and 2011, when antiretroviral therapy (ART) was scaled up in a context of severe human resources shortages, transferring responsibility for elements in human immunodeficiency virus (HIV) care from conventional health workers to lay counsellors (LCs) contributed to increased uptake of HIV services in Lesotho. HIV tests rose from 79 394 in 2006 to 274 240 in 2011 and, in that same period, the number of people on ART increased from 17 352 to 83 624. However, since 2012, the jobs of LCs have been at risk because of financial and organizational challenges. We studied the role of LCs in HIV care in Lesotho between 2006 and 2013, and discuss potential consequences of losing this cadre. Methods included a case study of LCs in Lesotho based on: (1) review of LC-related health policy and planning documents, (2) HIV programme review and (3) workload analysis of LCs. LCs are trained to provide HIV testing and counselling (HTC) and ART adherence support. Funded by international donors, 487 LCs were deployed between 2006 and 2011. However, in 2012, the number of LCs decreased to 165 due to a decreasing donor funds, while administrative and fiscal barriers hampered absorption of LCs into the public health system. That same year, ART coverage decreased from 61% to 51% and facility-based HTC decreased by 15%, from 253 994 in 2011 to 215 042 tests in 2012. The workload analysis indicated that LCs work averagely 77 h per month, bringing considerable relief to the scarce professional health workforce. HIV statistics in Lesotho worsened dramatically in the recent era of reduced support to LCs. This suggests that in order to ensure access to HIV care in an under-resourced setting like Lesotho, a recognized and well-supported counsellor cadre is essential. The continued presence of LCs requires improved prioritization, with national and international support.
authors.affiliation: Médecins Sans Frontières, Operational Centre Brussels, Brussels, Belgium, mariellebemelmans@hotmail.com.
authors.forename: Marielle
authors.initials: M
authors.lastname: Bemelmans
authors.affiliation: Médecins Sans Frontières, Operational Centre Brussels, Roma, Lesotho.
authors.forename: Delphine
authors.initials: D
authors.lastname: Goux
authors.affiliation: Médecins Sans Frontières, Southern Africa Medical Unit, Cape Town, South Africa.
authors.forename: Saar
authors.initials: S
authors.lastname: Baert
authors.affiliation: Médecins Sans Frontières, Operational Centre Brussels, Roma, Lesotho, Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town.
authors.forename: Gilles
authors.initials: G
authors.lastname: van Cutsem
authors.affiliation: Médecins Sans Frontières, Operational Centre Brussels, Roma, Lesotho.
authors.forename: Mabaruti
authors.initials: M
authors.lastname: Motsamai
authors.affiliation: Médecins Sans Frontières, Operational Centre Brussels, Brussels, Belgium.
authors.forename: Mit
authors.initials: M
authors.lastname: Philips
authors.affiliation: Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
authors.forename: Wim
authors.initials: W
authors.lastname: van Damme
authors.affiliation: United States President's Emergency Plan for AIDS Relief (PEPFAR), Maseru, Lesotho and.
authors.forename: Hilary
authors.initials: H
authors.lastname: Mwale
authors.affiliation: Médecins Sans Frontières, Operational Centre Brussels, Brussels, Belgium.
authors.forename: Marc
authors.initials: M
authors.lastname: Biot
authors.affiliation: Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Thomas
authors.initials: T
authors.lastname: van den Akker
mesh_terms: D003376:Counseling / Q000379:methods*; D000072117:Counselors / Q000191:economics / Q000600:supply & distribution*; D005544:Forecasting; D015658:HIV Infections / Q000175:diagnosis / Q000628:therapy*; D006291:Health Policy; D006801:Humans; D007927:Lesotho; D008403:Mass Screening; D011203:Poverty; D035501:Uncertainty
keywords: ART; HIV/AIDS; Lesotho; community health worker; health policy; health system; human resources for health; lay counsellors