Strengthening National Expertise in PrEp and Expanding Cervical Cancer Services: EGPAF-Lesotho Technical Assistance Support to Baylor College of Medicine Children’s Foundation
Established in 2005, the Baylor College of Medicine Children’s Foundation – Lesotho (BCMCFL) is an independent organization based in Maseru. This local partner engages in clinical research and provides pediatric and family-centered care. Because there are currently no medical schools in Lesotho, BCMCFL also offers vital on-the-job training for national medical professionals and allied health workers. Services offered through Baylor include HIV and TB prevention and treatment (including pre-exposure prophylaxis [PrEP]) and cervical cancer screening.
In 2019, BCMCFL was awarded the Expanding TB and HIV Clinical Services (ETHICS) project. ETHICS called for the organization to support Ministry of Health (MoH) facilities in two districts: Butha-Buthe and Mokhotlong. This required BCMCFL to expand its technical scope and extend service coverage beyond its Centers of Excellence. Accordingly, EGPAF partnered with this organization to scale-up services and capacities in the areas of PrEP and cervical cancer screening.
Strengthening National Expertise in PrEP and Enhancing Local Networks
Technical Capacity Assessment
Early into ETHICS implementation, BCMCFL recognized that donor targets for PrEP initiation and adherence were not being met. A TCA was conducted to help the partner determine suitable strategies to strengthen its PrEP services. EGPAF identified specific barriers to the intended scale-up, along with existing gaps in clinical areas. Across BCMCFL’s 26 supported sites, staff had varying (but largely low) confidence about screening for PrEP eligibility.
Training of Trainers
EGPAF provided technical assistance for PrEP eligibility screening, initiation, and adherence. A PrEP curriculum was incorporated into ongoing HIV case identification training for BCMCFL’s district-level professional counselors. Counselors held step-down PrEP refresher training sessions for clinical staff and provided mentorship at all BCMCFL-supported facilities. Clinical staff reported feeling more confident and competent in their provision of high-quality PrEP services. Paired with the staff’s greater understanding of (and capacity to use) the Ministry of Health tools, the organization made significant progress: achieving 40% of the FY20 annual target for clients initiated on PrEP in Q4 alone.
Sustainability
Information gleaned from the TCA and the documentation and quality control training prompted BCMCFL to address service delivery issues through a coordinated, organization-level response. This Action Plan included additional interventions to address the needs of underperforming facilities. While checking for consistent quality across facilities, BCMCFL discovered that three were not yet initiating clients on PrEP.
To aid these lagging facilities, counselors implemented a series of TA approaches they learned through EGPAF’s training and mentorship. First, they conducted a standard step-down refresher training (modeled after EGPAF’s) to raise PrEP awareness among providers at the facility. Later, district-based teams of counselors and clinical staff visited each of the targeted facilities to provide more in-depth training and mentorship through interventions tailored to their specific needs.
“Our EGPAF colleagues are always readily available to support us, either formally or informally through a WhatsApp message. Whenever we require assistance, we know that we can always reach out to the EGPAF team for assistance.”
Dr. Limpho Seeiso, BCMCFL’s Senior Advisor for Prevention
As a result of EGPAF mentorship and TA, BCMCFL:
Because EGPAF and BCMCFL have a lengthy history of collaboration, staff had existing intra-organizational relationships. This made for productive mentorship efforts and easy exchange of best practices and lessons learned.
Taking inspiration from EGPAF advisors, BCMCFL opted to forego the usual slow down typical of the holiday season: ensuring consistent presence in its facilities from November through January. This time was used to implement an index testing project that incorporated PrEP.
Significantly, BCMCFL managed to extend services to migrant workers – a population it would have missed if not for the timing of this initiative.
By recreating successful practices shared through the learning network, BCMCFL successfully implemented an approach commonly used by EGPAF to improve their project performance.
Expansion of Quality Cervical Cancer Services
In 2019, BCMCFL was tasked with extending its cervical cancer screening services to MoH-supported facilities in the Butha-Buthe and Mokhotlong districts. In support, EGPAF partnered with this organization to identify barriers to program expansion. The TCA revealed a lack of cervical cancer screening and treatment guidelines, inconsistent knowledge and skill levels among service providers, and insufficient documentation and data monitoring processes.
Training of Trainers
EGPAF developed and implemented theoretical and practical training sessions for cervical cancer screening and treatment. World renowned cervical cancer authority, Dr. Oluwasanmi Akintade, was tasked with developing a curriculum. An in-house expert at EGPAF with a long history of working with women in Lesotho, Dr. Akintade was well placed to provide a context-specific intervention. While many nurses already had some cervical cancer training, it was largely practical and not theoretically learned in school. EGPAF’s refresher training emphasized the theoretical aspect first followed by practical lessons, which enabled screening to become a more urgent priority in the partner’s program.
Nurses who completed this process were appointed to BCMCFL-supported sites, where they provided step-down training and mentorship to fellow nurses at those facilities.
Using this approach, BCMCFL developed a network of trainers that could ensure that standards were maintained as information and skills were distributed.
EGPAF also collaborated with BCMCFL to develop a set of test-and-treat standard operating procedures. These were based on best practices and lessons learned from EGPAF’s extensive experience with cervical cancer screening. One notable recommendation encouraged BCMCFL to begin using thermocoagulation as a treatment method. Not only was it more fitting for the Lesotho context – it was more conducive to rapid service expansion in that space.
Using Mentorship to Build a Data-Driven Culture
TA support largely focused on increasing the frequency of data reporting. Weekly reports gave way to real-time (virtual) reports of daily data, which allowed BCMCFL was to set more regular (weekly) data reviews. This change made the organization more inclined toward action-oriented data responses. Through these enhanced data review practices, BCMCFL can drill down to specific areas or facilities that require tailored interventions. Where applicable, lessons learned from these efforts are incorporated into the ETHICS project and the organization itself.
As a result of EGPAF mentorship and TA, BCMCFL:
Increased its cervical screening capacity from 33 clients in November 2020 to 1,831 at the close of September 2021
Achieved 98% of its donor-set screening target
Expanded services to all its target facilities using a combination of facility-based and mobile teams
Enhanced organizational knowledge and skill as it grew in scale
