Evaluating a Community-Based Directly Observed Therapy Programme for HIV Patients with Virological Failure in Lesotho’s Mokhotlong District: A Policy Analysis

High rates of virological failure among people living with HIV in Lesotho present a significant public health challenge. This is exacerbated in remote, mountainous regions like Mokhotlong District, where facility-based adherence support is often inaccessible. This policy analysis evaluates a community-based directly observed therapy (CB-DOT) programme for patients with virological failure in Mokhotlong District. It aims to assess the programme’s effectiveness, identify operational challenges, and analyse policy implications for scaling similar interventions. A qualitative policy analysis was conducted using a case study design. Data were gathered through a review of programme documents and policy frameworks, supplemented by in-depth interviews with key stakeholders, including programme managers, community health workers, and enrolled patients. The CB-DOT programme improved patient adherence and was viewed as a critical intervention in a hard-to-reach area. A principal challenge was a high attrition rate among community health workers, with a substantial proportion leaving their posts within the first year. This was primarily attributed to inadequate remuneration and logistical support, which strained the programme’s sustainability and coverage. While the CB-DOT model shows promise for managing virological failure in remote settings, its long-term viability is threatened by systemic weaknesses in community health workforce support. The programme’s success is contingent on parallel investments in health systems strengthening. Policy recommendations include integrating sustainable incentive structures for community health workers into national health policy, developing standardised CB-DOT guidelines for mountainous regions, and fostering stronger linkages between community and facility-based HIV services. HIV, virological failure, directly observed therapy, community health workers, health policy, Lesotho, adherence This analysis provides evidence for policymakers considering the adoption or scale-up of community-based adherence support models in resource-limited and geographically challenging settings.