We conducted a mixed method study to evaluate the pilot of community ART groups (CAG's) in Lesotho. Method: At the end of 2012 CAGs were piloted in Nazareth clinic, a facility in rural Lesotho. In CAG's stable patients take turns to collect antiretroviral therapy (ART) for fellow group members. Kaplan-Meier techniques were used to estimate retention among stable patients in CAG and not in CAG. Eight focus group discussions with 40 purposively selected CAG members, nine village health workers, six community leaders and nine clinicians provided insights in how CAGs are perceived by different stakeholders. The thematic analysis approach was employed for data analysis. Results: Among 596 stable patients 199 (33%) had joined a CAG. One year retention among CAG members and patients not in CAG was 98.7% (95% CI, 94.9-99.7) and 90.2% (95% CI, 86.6-92.9) respectively. CAG members commented that membership in CAG: 1) reduced time, effort, and money spent to get a monthly ART refill; 2) induced peer support, which enhanced adherence, socio-economic support and empowered members to deal with stigma; and 3) resulted in a feeling of relief and comfort. Village health workers confirmed increased openness about HIV in their community. Community leaders added that CAG members promoted health seeking behaviour to community members. Clinicians reported a workload reduction. Conclusion: Participation in CAG impacted positively on the lives of members, not only on their access to ART, but also on their life within the community.

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.