Training Community Health Workers to Scale-Up HIV Care in Rural Lesotho: Implementation Lessons from the Field

doi:10.4236/wja.2012.23019

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World Journal of AIDS, 2012, 2, 135-142

http://dx.doi.org/10.4236/wja.2012.23019 Published Online September 2012 (http://www.SciRP.org/journal/wja) 135

Training Community Health Workers to Scale-Up

HIV Care in Rural Lesotho: Implementation Lessons

from the Field

Jonas Rigodon1, Keith Joseph1, Salmaan Keshavjee2, Corrado Cancedda2, Mona Haidar3,

Nicolas Lesia1, Limpho Ramangoaela1, Jennifer Furin4,5*

1Partners in Health, Boston, USA; 2Harvard Medical School, Boston, USA; 3Lebanese American University, Beirut, Lebanon; 4Case

Western Reserve University, TB Research Unit, Cleveland, USA; 5School of Medicine, Case Western Reserve University, Cleveland,

USA.

Email: *[email protected]

Received July 2nd, 2012; revised August 2nd, 2012; accepted August 10th, 2012

ABSTRACT

Community health workers (CHWs) have long played an important role in the management of complex health problems,

especially in resource-poor settings. Although there is a large literature regarding the use of CHWs around the world,

there is little detail about how these workers are selected, train ed and u tilized in th e field. Leso tho has on e of the high est

rates of HIV in the world, with an estimated 25% of the general population infected with the disease; at the same time,

there is a significant health human resources shortage in Lesotho with an estimated 60% of health posts left vacant.

Community health work ers have the po ten tial to play a major role in HIV treatment scale- up in th e countr y, and in 2006,

a CWH-based project called “The Rural Initiative” was started in the remote mountain regions of the country. More

than 1000 CHWs were trained and employed through this program between June 2006 and December 2008. This paper

will review the CHW program in detail, with a focu s on recruitment, training , ongoing supervision and support, and the

larger public health implications of the CHW program in Lesotho. It is hoped this program can serve as a practical

model for other programs working with or in need of CHWs.

Keywords: Lesotho; Community Health Workers; HIV

1. Introduction

Community health workers (CHWs) are a group of

health para-professional that have been used to treat

myriad disease problems for decades [1]. Beginning with

the “barefoot doctors” in rural China [2], CHW-based

programs have expanded globally and there is an esti-

mated 1.3 million such workers used in health programs

around the world [3]. Although programs use varying

definitions of CHWs, they are generally defined as indi-

viduals with little formal training in health but with gr eat

expertise in knowledge of the population and regions in

which they work [4] When provided with program-spe-

cific training and support, these individuals play a key

role in supporting and implementing health programs in

the field [5]. Their activities can include disease screen-

ing, disease prevention health education, adherence sup-

port, and community mobilization [6-8].

CHWs are involved in the management of multiple

diseases ranging from diabetes [9] to mental health [10]

to TB [11,12]. One health area in which CHWs have

been invaluable is in the prevention, support and tre a tment

of HIV [13-15]. CWHs have been a cornerstone in scaling

up HIV prevention and treatment all over the world; they

have been especially important in the high-burden HIV

countries of southern Africa where there are also extreme

shortages of trained health professionals [16-18].

Lesotho is one such country, with an estimated HIV

seroprevalence of 25% [19]. Health care worker short-

ages are glaring in this country of two million people,

with an estimated 80 physicians in the country and 60%

of nursing posts vacant [20]. This health care worker

shortage is acutely felt in the rural regions of the country,

where health posts and clinics are often un-staffed and

little is offered to these populations in terms of primary

care let alone preventing testing and treating HIV [21].

In June of 2006, a program called the Rural Health ini-

tiative (RHI) was launched in the mountains of Lesotho

to provide comprehensive HIV testing and treatment ser-

vices to the populations there [22]. CWHs were an inte-

gral part of this program and were recruited and trained

*Corresponding a uthor.

Training Community Health Workers to Scale-Up HIV Care in Rural Lesotho: Implementation Lessons from the Field

136

from the local populations as soon as the program began.

Although much has been written about the use of CHWs

in managing HIV, there is little scholarly literature about

how CWHs are selected, trained, and supported in their

work. This paper fills that gap by providing such infor-

mation on CWHs at one clinic participating in the RHI.

2. Setting

In 2006, a joint program—involving The Ministry of

Health and Social Welfare of Lesotho (MOHSW), the

US-based NGO Partners In Health, The Division of

Global Health Equity o f Brigham and Women’s Hospital,

Boston, The Clinton HIV/AIDS Initiative, and Irish

Aid—called the Rural Health Initiative (RHI) was

launched [23]. The goal of this program was to increase

access to HIV care and treatment in rural Lesotho. The

program focused on sev en mountain clinics and an inten-

sive effort was made to introduce HIV services into set-

tings of primary care [24]. As part of this program,

CHWs were recruited and trained to assist in treatment

adherence, active case finding, community mobilization,

and patient education. The CHW component of this pro-

gram was based on successful CWH program imple-

mented in Haiti, Peru and Rwanda by Partners in Health

[25]. Since starting in June, 2006, the RHI has provided

primary care services to hundreds of thousands of indi-

viduals. Between June, 2006 and December, 2008,

13,887 individuals underwent HIV testing through the

program. The RHI enrolled 4521 patients in HIV care

and started 2354 on ART during this period of time.

More than 85% of patients started in treatment remained

on therapy as of December 31, 2008 [26]. A total of 1012

CHWs were trained as part of this work.

One clinic in the Mohale’s Hoek region called “No-

hana clinic” was the first site to begin implementing the

RHI model. It was selected for logistical reasons and

because there was a great deal of political and commu-

nity support in the region. Because it was the first and

most active clinic, the CHW program at Nohana clinic is

the focus of this report.

3. Methods

This report is based on field observations that occurred

over a 30 months time period by the authors using stan-

dard qualitative techniqueds [27]. These observations

were made as part of ongoing operational research [28]

to understand and improve the services of the clin ic. Key

program components and issues were identified and are

described in the results section below.

4. Results

4.1. Existing Networks of CWHs

CHWs were already an established part of the health

system in Lesotho at the time the RHI started. Each vil-

lage had one or two individuals—usually women—who

were selected by the village chief to be a CHW. Prior to

the RHI, these women had nebulous roles in their com-

munities and were asked to be responsible for “the health

of the village”. They were not paid for any of their work

nor were they assigned any specific tasks. They were not

offered any ongoing training and received little to no

support in the field. Many of them were too elderly to

make visits to individuals living in their villages, and

they themselves were often infected and sick with HIV.

There was no infrastructure in which they could operate

and no chain of command. Thus, although theoretically

in existence, the CHWs were essentially defunct.

4.2. Program Components

4.2.1. Selection of CHWs

The RHI was committed to using CHWs in the scale-up

of HIV care in the mountains of Lesotho. This decision

was made based on the group’s prior experience with

successful HIV treatment programs in both Haiti and

Rwanda [29]. The first task for the clinic team was to

identify individua ls who were willing to participate in th e

RHI program. The program planned to initiate treatment

in at least 300 patients in the first 3 months of operations.

Based on prior work, a ratio of 1 CHW to 4 or 5 patients

was felt to be optimal. In order to accommodate these

patients and to allow for CHW drop out, 75 CHWs was

the target number fo r initial recruitment.

As noted in the section above, networks of CHWs al-

ready existed in the mountains of Lesotho, and it was

from this pool of individuals that the original 75 CHWs

were selected. There were 34 villages surrounding No-

hana Health Center, and the chiefs and CHWs from each

village were approached by clinic staff and asked about

their willingness to participate in the program. In some of

the villages, the existing CHWs were either dead or did

not express interest in the program. In these cases, the

chief was asked to nominate an additional CHW(s) who

were willing to participate. Most villages had two CHWs

each, although some had one and others had three.

Ninety percent of the CHWs were women. All of the

CHWs could read and write.

4.2.2. Initial Training

An initial 5 day training program was conducted at No-

hana health center in June of 2006. All 75 CHWs par-

ticipated in the training. The curriculum was based on a

successful HIV training course for CHWs developed in

Haiti and then adapted to Rwanda [30]. Topics covered

in the curriculum are listed in Table 1. The curriculum

was translated into the local language of Sesotho and

cultural adaptations were made by a trained anthropolo-

gist.

Training Community Health Workers to Scale-Up HIV Care in Rural Lesotho: Implementation Lessons from the Field

137

Table 1. Topics covered in initial training.

Training Day Unit Topic

Day 1 1 Introduction and overview of CHWs and HIV

2 HIV basic facts

3 Prevention and transmission of HIV

4 Treatment of HIV

Day 2 5 Side effects of antiretrovira l therapy

6 Women and HIV (including p revention of maternal to c h i l d t ransmission and family p l a n n i n g )

7 Other sexually transmitted diseases

Day 3 8 Stigma and discrimination

9 Psychosocial support and e ff ec tiv e communication

10 Tuberculosis

11 Tuberculosis treatment and side effects

Day 4 12 Other opportunistic infections

13 Nutrition and HIV

Day 5 14 Roles and responsibilities of CH Ws

15 Confidentiality

16 Challenges faced by CHWs

Trainings were led by the RHI team and the Nohana

Clinic Staff. Training was conducted in Sesotho or in

English with a Sesotho translation. Each CHW was given

a training manual and a CHW notebook for their work.

During their training, the CHWS were shown slides

relevant to the topics of discussion. Multiple case studies

were discussed during the training in both small and

large groups.

4.2.3. Job Responsibilities

CHWs were paid a per diem of 50 maluti per day (8

USD). They were also given two meals during the train-

ing. Any transport costs they incurred were reimbursed,

and for those living far from the health center, overnight

accommodations were provided. All 75 participants

completed the 5 day training. Photos of the training are

shown in Figures 1 and 2.

Figure 1. CHWs at nohana training.

The CHWs were all given very clear job responsibili-

ties and tasks for which they would now be responsible.

The activities focused on four main areas: 1) daily con-

tact with individuals on antiretroviral therapy to ensure

mediations were being taken correctly and to assess for

any clinical changes that would prompt a visit to the

health center (i.e. signs of adverse effects, signs of possi-

ble new opportunistic infections, etc.); 2) accompanying

all patients with HIV to scheduled clinic visits; 3) identi-

fication of individuals in the village who appear to be in

need of medical care and either bring them to the clinic Figure 2. CHWs at monthly meeting.

Training Community Health Workers to Scale-Up HIV Care in Rural Lesotho: Implementation Lessons from the Field

138

for care, or if the person was too sick to get to the clinic,

arrange for clinical staff to do a home visit; and 4) gen-

eral community outreach and education about HIV and

other health concerns. Each of these will be described in

more detail.

1) Daily contact with individuals on antiretroviral

therapy.

CHWs were responsible for making a daily visit to

each person in their village who was on ART. The pur-

pose of the home visit was to ensure that medications

were being taken as prescribed and to answer any ques-

tion the patient and his or her family might have about

the medications. CHWs were trained about the basic an-

tiretrovirals and were given a medication list for each

patient in their village to ensure the patient had the cor-

rect medications. If there were discrepancies, the CHW

went to the health center to verify the medication regi-

men. The daily visits also served as a way to assess the

general health status of the patient. CHWs were trained

to ask a series of basic screening questions regarding

signs or symptoms that needed further assessment. If

these symptoms were present, th en the CHW notified the

clinic for follow-up. In addition to these duties, the

CHWs were asked to do the following at each daily visit:

provide physical and emotional support for the patient

and his or her family; identify other members of the

household in need of clinical assessment; assess social

and economic factors that might impact patients’ health;

and provide directly observed therapy for other medica-

tions (i.e. TB treatment).

2) Accompany all patients with HIV to scheduled

health center appointments.

CHWs were assigned to accompany all HIV-positive

individuals to their scheduled visits at the health center.

The purpose of this was to ensure that patients were able

to keep their scheduled appointments. Having both the

CHW and the patient at the clinic appointment also en-

sured that the CWH and patient were given the same

information on the patient’s treatment plan for the com-

ing months. Finally, the CHW was also asked to come to

the visit to be an advocate for the patient and raise any

concerns that the patient may not be comfortable voicing

to providers. With regard to the health center appoint-

ments, the CHWs were asked to do the following: Re-

mind patients of upcoming appointments at the clinic;

work with the patient to make a list of top ics to d iscuss at

the appointment; escort patients to the clinic for their

appointments; arrange for safe and reliable transport for

patients not able to walk to clinic; record in their CHW

notebook the treatment plan for each patient; discuss the

list of patient concerns with the providers; document the

date of the next appointment.

3) Identify individuals in the community in need of

medical attention.

Most of the villages that utilized Nohana health center

were located some distance from the clinic. On average,

people had to walk two to three hours over rugged terrain

to reach the clinic. At the start of the program, many of

the patients with HIV were too ill to walk to the health

center. Thus, CHWs were asked to identify persons in

their villages who were ill and in need of medical atten-

tion. When possible, the clinics worked with the CHWs

to arrange transportation to the clinic. In many cases,

however, there were no means of transporting the patient

to the clinic outside of carrying him or her. When this

was the case, CHWs reported to the clinic and arranged

for home visits to be made to the community members.

During these home visits, the CHW came to the clinic

and took the clinic staff (usually a physician or nurse) to

the home or homes of those individuals in need of care.

HIV testing and ART initiation was then done in the

home for those in need of it. Patients could also undergo

TB testing and TB treatment initiation in the home as

well. Other basic medical assessments could be done at

this time.

Home visits often served as a way to inform the com-

munity about the HIV and other programs at the health

center. It was often the case that multiple other individu-

als in need of assessment and care were identified. When

possible, these individuals were seen one the date of the

original home visit. If more individuals were identified

than could be seen, follow up visits were schedule. This

also included general community screenings for HIV,

malnutrition, vaccinations, and other community needs.

With regards to their work in identifying individuals in

the community in need of medical attention, CHWs were

specifically asked to: seek out individuals and families

who were felt to be “sick”; approach these individuals

and their families and ask if they would like a home visit

from clinic staff; report these individuals to the clinic

staff and plan for a transport or a home visit; accompany

clinic staff to the home or homes of id entified ind ividu als;

arrange for any follow-up needed for those seen on home

visits; schedule additional home visits for patients not

able to be seen at the original home visit; id entify at-risk

groups in need of community screening for HIV, TB,

nutritio n, and other health issues.

4) Provide general outreach and education to the

community.

CHWs were not only responsible to individuals with

identified health needs, but also to the community as a

whole. To this end, they were responsible for providing

the community with general education about HIV and

AIDS, including risk factors, transmission, prevention,

testing and treatment. CHWs were also responsible to

provide the community with education about other im-

portant health topics. Some of these topics were identi-

fied by the Nohana clinic staff as affecting the region (i.e.

Training Community Health Workers to Scale-Up HIV Care in Rural Lesotho: Implementation Lessons from the Field 139

vaccination campaigns, food shortages, etc.). Others were

identified by the community an d the CHWs worked with

the clinic staff to develop programs in these areas (i.e.

male circumcision, migrant labor and HIV, working with

traditional healers). More specifically, CHWs were asked

to: organize community workshops on HIV; organize

community HIV testing drives; advise community mem-

bers about clinic services; provide condoms for HIV

prevention; survey the community about pressing health

concerns; organize workshops for the community on

other health to pi cs.

4.2.4. Paymen t

All CHWs were provided with a monthly payment for

their work, the rate of which was determined by the

MOHSW at 100 Maulti per CWH per month (USD 15).

Payment was felt to improve the ability of the CHWs to

perform their jobs and demonstrate the importance of the

work they did. Many of the CHWs were themselves fac-

ing poverty and sickness, and it was felt that asking them

to “volunteer” to do such important work would be un-

sustainable. Although this was an initial up-front cost to

the program, it was felt that the benefits of keeping pa-

tients adherent and in treatment outweighed these costs.

After a year of successful implementation and payment

of the CWHs, the MOHSW of Lesotho decided to begin

paying all the CHWs in the country.

4.2.5. Ongoing Training

In addition to the initial broad training session, ongoing

education was offered in the form of monthly training

sessions. These trainings not only provided ongoing

educational material but also served to keep the CHWs

connected to the RHI and health facility staffs, update the

CHWs on information related to patients, diseases, and

program developments, and allow the CHWs a regular

forum to provide feedback. Regular trainings also rein-

forced the professionalization of the CHW’s roles. The

ongoing monthly trainings lasted between three and four

hours, and a meal was provided. Transportation costs to

attend the meeting were also subsidized.

In addition to ongoing training for existing CHWs,

cadres of new CHWs were needed to be recruited and

trained to meet expanding program needs. Given the ex-

pansion of clinical services in Nohana, an additional 65

CHWs needed to be trained and deployed in the field.

Additional CHWs were selected from persons either

nominated by the village chief or nominated by an active

CHW. These new CHWs then underwent the initial 5

days training, which was held quarterly for new recruits.

These CHWs then joined the ongoing training session

and worked closely with a more experienced CHW dur-

ing their first three months in the field.

4.2.6. Ongoing Support and Supervision

CHWs expressed the need for ongoing support from the

health centers. Some of this was done at the monthly

meetings discussed above. In addition, health center per-

sonnel also accompanied the CHWs into their communi-

ties and on home visits. Clinic staff provided ongoing

support and feedback to CHWs and also gave them for-

mal quarterly evaluations. Any problems that arose were

discussed with suggestions for improvements. CHWs

were relieved of their duties if they violated the privacy

or confidentiality of a patient or if they knowingly com-

mitted acts that jeopardized patients’ health.

CHWs themselves were supervised by the health cen-

ter staff but also by the patients they cared for and the

village as a whole. If there was a problem with a CHW,

the clinic staff was notified, and a meeting was held with

the clinic medical director and the CHW. Identification

and mitigation of problems was the goal of the meeting,

and most disputes could be solved. In settings where

CHWs violated patient confidentiality or did not provide

the patient with necessary medicines, that worker could

be terminated.

In addition to this support and supervision, newly re-

cruited and trained CHWs were matched with more ex-

perienced CHWs during their first three months in the

field. This support was not available for the initial 75

CHWs, and their supervision and support was provided

largely by clinic staff. Once this initial cadre gain ed field

experience, they took over the majority of supervision

and support of newly recruited CHWs. This provided

more frequent interactions with supervisors who had di-

rect experience with the responsibilities of the CHW an d

could offer practical, field-based advice. Quarterly su-

pervision and feedback was given to all CHWs by the

clinic staff.

4.3. Challenges

There were several challenges faced by the CHWs and in

the implementation of the CHW program in Lesotho.

Chief among these was stigma. Many patients expressed

a fear of having CHWs come to their homes. They felt

this might label them as having HIV. They also worried

that someone in their village might “gossip” about them

or share their status with others in the community.

This problem was managed by acknowledgement of

the potential for problems and a frank discussion with

CHWs and HIV patients. CHWs were trained in the

principles and application of confidentiality and privacy

on an ongoing basis. Those found to violate these princi-

ples received strict disciplinary action. In addition, once

patients were receiving treatment, a majority of them got

better, and stigma was lessened overall. The CHWs were

seen to play an important role in this, and they became

Training Community Health Workers to Scale-Up HIV Care in Rural Lesotho: Implementation Lessons from the Field

140

welcome visitors in the village among those with HIV.

A second problem was the distance most CHWs lived

from the clinic. Many had to walk 2 - 3 hours over

difficult terrain to reach the health center. This was a

problem if they identified a critically il l patien t in need of

emergent care. This was also a problem if they were

supporting several different patients who came to clinic

on different days. At the beginning of the program

CHWs who supported patients in other villages that are

several hours away led to neglect of patients

In order to address these issues, CHWs were given

transportation stipends. Efforts were made by the clinic

to schedule all the follow-up patients for one CHW on

the same day. Perhaps most importantly, new CHWs

were recruited and trained from all the villages, thus

leading to a situation in which most CHWs were in close

proximity to the patients they supported.

5. Conclusions

CHWs were crucial scaling up HIV treatment in rural

Lesotho, much as they have been in other programs

throughout the world. This paper discusses the practical

implementation of CHW program at Nohana clinic in

rural Lesotho, a resource-poor, high burden HIV setting.

CHWs were successful in starting and marinating thou-

sands of individuals on HIV therapy in this setting . They

were carefully selected from pools of existing CHWs

which had floundered in the absence of training and

support. They were largely female and could read and

write. They received initial and ongoing training for

HIV-related work using a curriculum developed in other

settings and adapted to Lesotho. They carried out a

number of activities, including community education and

mobilization, adherence support, and active case finding.

They were paid for their work and supported by health

center staff at the clinic. The CHWs in Lesotho were

highly motivated and successful at what they did, and it

is hoped their experience can be a model for other CHW

programs. In addition to their HIV work, CHWs could

also be successfully trained to manage other chronic

health problems, sustain existing communicable disease

prevention and treatment programs, and participate in

community mobilization and outreach on a number of

health issues.

There are multiple limitations to this paper. First, the

data reported is based on field observations conducted

over a 30 month time period in a single clinic. There may

be both historical and reporting bias inherent in these

results. In addition, this data is not generalizable to the

general population. Finally, the purpose of this research

was to describe the process of CHW selection, training,

and supervision and is not linked to outcomes at the pa-

tient or clinic level.

In spite of th ese limitat io ns , this paper o ffers impor tant

insight into the CHW program used to roll-out HIV pre-

vention and treatment services in the mountains of Leso-

tho. While there is much written about CHW programs,

there is little in the literatu re about th e selection, training,

payment, supervision , and spec ific responsibilities of th is

group of health paraprofessionals. This paper can assist

programs wanting to deploy CHWs define and carry out

the steps that are needed to ensure these workers can be

effective in the field of HIV care. Given the high burden

of HIV disease in the very settings where HIV is rampant,

such operational guidance is necessary to ensure that

HIV care is available to all.

6. Acknowledgements

The authors of this paper are most thankful to and mind-

ful of the men and women of Lesotho who inspire us

with their daily courage in the fight against HIV. We are

also thankful to all the clinic staff who provided daily

care to those living with HIV and AIDS. For program

support work we acknow ledge and are thankful to Jaclyn

Chai, Bob Hsiung, Cheryl Snyder, Ted Constan, Jeremy

Keeton, Hind Satti, and Kwonjune Seung. This work

would not have been possible without the Ministry of

Health and Social Welfare of Lesotho and our other im-

plementing partners, including the Clinton HIV/AIDS

Initiative, Mission Aviation Fellowship, and Catholic

Relief Services. For funding support, we thank Irish Aid,

the Francois Xavier Bagnoud Center for Health and Hu-

man Rights at the Harvard School of Public Health,

Partners in Health, Thomas J. White, and Frank Hatch.

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