Oh Canada, Oh Lesotho

A Canadian charity heeds the call to fight HIV in sub-Saharan Africa. 

Dr. Philip Berger remembers vividly what it sounds like to die from PCP (pneumocystis pneumonia), the life-threatening pneumonia that killed so many HIV-infected people in the early days of the epidemic. “Patients would be breathless by the time they walked from my waiting room to the examining room,” says the Toronto doctor, who treated hundreds in the 1980s and ’90s when HIV was still a death sentence. “I called this the walk test, and it almost certainly confirmed the diagnosis.” PCP, one of the most serious of several opportunistic infections HIV patients can fall prey to, essentially causes AIDS and, if untreated or caught early, death. 

When Berger arrived at the Tšepong HIV clinic in Leribe, Lesotho, in late 2004, he heard the familiar, haunting sounds of people gasping for life. “In my practice in Toronto I saw one case a week—and that was considered a lot even in those days. In Lesotho, I saw six, seven, up to 10 a day.” With the clinic barely functional, most who came in were extremely ill, often within days, sometimes hours of death. “In the first week I was there, I had a woman who weighed 37 kilograms, was completely white under her eyelids, very sick, and no blood available for a transfusion. She died.” In fact, people were dying right in the clinic’s corridor, sometimes right at its door. The severity and volume of illness and death, says Berger, was greater than anything he’d seen as an AIDS physician in Canada.

Now five years later, that outlook is changing in Leribe, in part because of OHAfrica, a Canadian charity founded after Hilary Short, then head of the Ontario Hospital Association (OHA), heeded a call by Stephen Lewis, then UN Special Envoy for HIV/AIDS in Africa, for Canadian action in the HIV-ravaged continent. Funded in stages by The Change Foundation and Greystone Health Trust, as well as the Bracelet of Hope campaign out of Guelph, Ont., Lesotho was chosen because, though a nation of just two million people, it has the third-highest HIV infection rate in the world. Astonishingly, 23 percent of the adult population are HIV positive, as are an estimated 12,000 children under the age of 14, according to UNAIDS. On average 50 people die from AIDS in Lesotho every day, another 60 are newly infected, and about 108,000 kids have been orphaned by the disease. Moreover, as more women than men are stricken, an urgent need exists to get the medicines to pregnant woman so that HIV is not transmitted to an unborn baby.

In the district of Leribe, where approxi-mately 43,000 people are thought to have HIV, virtually no treatment, no patient care for HIV or AIDS existed when the OHAfrica team arrived. “People were dying in their villages, in their homes,” says Alicia Homer, director of operations almost since the charity’s inception. And as in most of Lesotho at the time, there was no access to the antiretroviral drugs (ARVs), which in the last decade have transformed HIV infection from a terminal diagnosis to a manageable condition.

The initial plan of OHAfrica was to send Canadian health professionals to Tšepong to teach local staff HIV patient care and health-care protocols. That changed quickly, when Berger, the first doctor assigned to the clinic, arrived. Word travelled that the clinic was offering access to the life-saving ARVs—for free (funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria, and distributed by the Lesotho Ministry of Health and Social Welfare). Tšepong went from treating a trickle of very sick people “to being bombarded with patients,” says Homer, upwards of 100 a day—this, despite a chronic lack of viable transportation that forced people to walk hours and miles just to get to it.        

Meeting the unexpected onslaught of patients was a challenge, with the clinic itself needing so much work. Apart from limited staff and basic supplies—like soap to wash hands—no triage system was in place. So, in addition to testing and treating for HIV, the Canadian team began hiring and training local nurses, support staff and pharmacy technicians, and put plans in place to revamp the facility. Many patients also had to be treated for TB, which HIV patients are susceptible to contracting, and is now rampant in Africa. “The second thing we did to prevent thousands of lives being lost was to prevent PCP,” says Berger, who began teaching staff how to spot its symptoms, and put a protocol in place for aggressive prophylactic treatment. In 2007, an addition to the clinic was built to house a new pharmacy as well as a patient counselling unit, and last year a much-needed waiting room was added. An HIV-support group has also sprung up.

Tšepong had only 116 patients registered and nine on ARVs in 2004; by the close of 2009, the roster stood at more than 11,300, and every patient diagnosed in need of the antiretrovirals had access to them. (Not all HIV-positive people need ARV therapy.) Overall, more than 45 Canadian health-care providers, including pharmacists, have served at Tšepong, and with more than 400 people being tested and treated every month, OHAfrica reports it’s one of the busiest in Lesotho. The clinic now has more than 30 people on staff, with the charity covering the salaries of 23. On his last stint in January of this year—he’s done three—Berger, a self-described cynic, says the transformation has been impressive, and Tšepong rivals most primary care clinics he’s seen in Canada. Many of the patients he treated in 2005, ones so sick with PCP they could barely breathe, were now almost healthy, albeit HIV-positive.

Above getting the clinic operational, the Canadians have also worked in partnership with the Lesotho government to train staff in HIV testing and treatment at 23 rural health centres that have been built over the past four years, as the country’s health system slowly takes shape. ARVs are also now distributed through the centres. Ironically, says Homer, the availability of the drugs in Leribe has dramatically shifted attitudes toward HIV-infection: as people saw loved ones cured, or given medicines that staved off illness, more have been willing to learn their HIV status, and patients coming into Tšepong and the centres are much healthier than ones in the past. Homer says it’s a myth people in Africa have to be persuaded to take the ARVs, or to take them as prescribed. They absolutely want the drugs, absolutely want to live, want to give their children a chance.

As part of its national AIDS strategy—which includes a “Know Your Status” campaign—the Lesotho government wants Tšepong back in local hands. The Canadians are packing up and heading home. OHAfrica, then, can be described as a victim of its success. Yet the question remains: how will the clinic fare without OHAfrica support? Staffing may be an obstacle; while finding nurses hasn’t been a problem, Lesotho has no medical school, and in 2007 the Global Fund, reported only 89 doctors were serving the entire country—most of them imports. But the Lesotho doctor taking the helm has extensive experience in HIV treatment, including training at Tšepong itself. More importantly, adds Berger, she’s absolutely fierce, a force to be reckoned with—just as AIDS is.

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