World Journal of AIDS, 2012, 2, 135-142 Published Online September 2012 ( 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,
Email: *
Received July 2nd, 2012; revised August 2nd, 2012; accepted August 10th, 2012
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.
Copyright © 2012 SciRes. WJA
Training Community Health Workers to Scale-Up HIV Care in Rural Lesotho: Implementation Lessons from the Field
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-
Copyright © 2012 SciRes. WJA
Training Community Health Workers to Scale-Up HIV Care in Rural Lesotho: Implementation Lessons from the Field
Copyright © 2012 SciRes. WJA
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
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
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
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.
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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
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Training Community Health Workers to Scale-Up HIV Care in Rural Lesotho: Implementation Lessons from the Field
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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