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Lesotho is a small country where 23,000 people died from AIDS in 2006, and more than 20% of the population are HIV positive. The country is also struggling to cope with 97,000 AIDS orphans. Crippling poverty combined with the AIDS epidemic has caused average life expectancy to drop to 44 years for women and 39 for men.¹ 

“AIDS has the potential to wipe out a whole nation” -Keketso Sefeane, Lesotho National AIDS Commission²

History of AIDS in Lesotho

Lesotho’s first AIDS case was reported in 1986. Since then the government has struggled to take concrete action against HIV/AIDS due to poor finances and infrastructure. The National AIDS Prevention and Control Programme was initiated in 1987,³ and sentinel surveys were introduced by 1992 to monitor the spread of HIV every two years. However surveys were inconsistent until 2000 due to lack of funding and technical problems.⁴

In 1996 the government introduced a new AIDS programme. Through joint efforts with community-based organisations and the United Nations, support of orphans and children living with HIV was improved. By that year HIV prevalence had shot up to 26% among pregnant women aged 20 to 24, from 3.9% in 1992.⁵

In 2000 the government released the Multisectoral National AIDS Strategic Plan. This intended to reduce HIV prevalence by 5%, increase annual condom use by 50% and provide care for half of Lesotho’s AIDS orphans, all by 2003. It also aimed to mobilise resources to co-ordinate the national AIDS response, improve information and communication on HIV/AIDS, and improve sentinel surveillance of HIV.⁶

In 2001 the Lesotho AIDS Programme Co-ordinating Authority (LAPCA) was established to implement the new strategy. Unfortunately inadequate skills and financial resources constrained LAPCA’s capacity. Even though HIV prevalence did not rise significantly between 2000 and 2003, the goal of reducing HIV prevalence by 5% by 2003 was not achieved. In 2003 King Letsie III declared HIV/AIDS a national disaster.⁷

By 2005 LAPCA was replaced by the semi-autonomous National AIDS Commission (NAC) and National AIDS Secretariat (NAS) to co-ordinate existing strategies for tackling the AIDS epidemic.⁸

In March 2004, Lesotho introduced an innovative strategy to increase HIV testing, raise awareness and reduce stigma for the whole population. The “Know Your Status” Testing Campaign is now underway to provide universal voluntary testing and counselling.⁹

In addition to this scheme, Lesotho’s AIDS effort is now guided by the National AIDS Policy and Strategic Plan for 2006-2011.¹⁰ The government intends to reverse the epidemic by focussing on HIV prevention through condom promotion, prevention of mother to child transmission, and providing antiretroviral treatment for all those in need.¹¹

The Impact of HIV/AIDS in Lesotho

“There are two types of people in Lesotho: Those infected and those affected by HIV/AIDS”. – CARE Lesotho ¹²

The HIV/AIDS epidemic in Lesotho has devastated the productive adult population aged between 15 and 49.¹³ The impact on individuals, families and the whole nation is being felt as adults become too sick to work, and children orphaned to AIDS are left to run households. Considering that more than half Lesotho’s population live in poverty, declining productivity as a result of HIV/AIDS remains a stark threat to the overall survival of the country.¹⁴

HIV/AIDS has had a particular impact on women. There are currently 150,000 women over the age of 15 living with HIV in Lesotho.¹⁵ Women lack political, financial and social rights, and in most cases are unable to resist demands for sex or even negotiate for practices that would protect their health.¹⁶ A law has been passed granting equal status to married women,¹⁷ which it is hoped will change women’s subordinate status in Lesotho’s traditional culture, in order that they can better protect themselves from HIV.

Prevention

The government of Lesotho has implemented several HIV prevention strategies, including educational campaigns, work-based HIV prevention initiatives, targeting high-risk groups and prevention of mother to child transmission.

Educational campaigns

In 2005 UNICEF and the government embarked on an interactive educational HIV/AIDS ‘roadshow’ designed to increase HIV awareness among young people. The roadshow provides entertainment such as talent shows, poetry, sports and dance, as well as life skills activities and educational tools explaining the spread of HIV. Counsellors and HIV tests have been made available at all roadshow events.¹⁸

To promote HIV/AIDS awareness at a young age, the topic has been included in the school curriculum at both primary and secondary school levels in subjects such as Health and Physical Education, Science, Agriculture, Home Economics, and Geography. ¹⁹

Workplace prevention initiatives

Lesotho’s largest employment sector is the textile industry, and factory owners and the government have recognised HIV/AIDS as a major threat to productivity. The majority of textile workers are women, one third of whom are estimated to be HIV positive. The Apparel Lesotho Alliance to Fight AIDS (ALAFA) was initiated in 2005 to provide free condoms, advice and antiretroviral therapy to workers. So far the scheme has helped more than 4,500 workers by making HIV services accessible. It is estimated that 1,850 lives could be saved every year with these interventions.²⁰

Condom Distribution

Low-priced male condoms have been supplied through community-based distribution systems in Lesotho since July 2001. In the first year of the project, the number of shops selling condoms in Lesotho almost tripled and the number of condoms distributed through the private sector more than doubled.²¹

Community organization SHARP! (Sexual Health and Rights Promotion) has provided free condoms through resource centres and local outlets such as police stations, village chief compounds and border posts.²²

Targeting high-risk groups

HIV awareness education and condom social marketing has been targeted towards sex workers, migrant labourers, factory workers, young people and long-distance taxi and truck drivers.²³ The 2002 Behavioural Surveillance survey found that knowledge about AIDS was particularly low amongst miners and taxi drivers.²⁴

In 2005, a scheme was launched in Lesotho’s capital, Maseru, to increase HIV awareness among hard-to-reach migrant workers and their families. The programme aims to increase knowledge of HIV/AIDS and condom usage, and access to voluntary counselling and testing services. Sporting tournaments, training and outreach activities promote HIV prevention and testing services.²⁵

Prevention of Mother to Child Transmission (PMTCT)

Every year in Lesotho an average of 7,000 babies become infected with HIV.²⁶ While sites providing services for the prevention of mother to child transmission of HIV (PMTCT) increased from 8 in June 2004 to 20 in December 2005,²⁷ many local health clinics, where most women access antenatal services, still do not offer PMTCT.²⁸ Paediatric services remain poor at best, as Lesotho has only 6 paediatricians to cater for the country’s 800,000 children.²⁹ In 2006 only 5% of HIV positive mothers in need of PMTCT services received them.³⁰

The government’s 2006 policy document on HIV/AIDS planned to provide universal access to free PMTCT services to all HIV positive women, and decentralise services to local health centres to bring services closer to the people.³¹ In 2007 new plans were released to reduce the risk of mother-to-child transmission by 80 percent by 2011.³²

Join AVERT’s Stop AIDS in Children Campaign to improve services for the prevention of mother to child transmission of HIV worldwide.

Universal HIV Testing

In March 2004, Lesotho’s government launched an ambitious voluntary counselling and testing campaign. This aimed for every member of the population over 12 to be tested for HIV by the end of 2007. Lesotho’s Prime Minister, Pakalitha Mosisili, launched the scheme, entitled “Know Your Status”, by testing publicly for HIV. The campaign intended to overcome the huge stigma that surrounds HIV/AIDS in Lesotho, which has prevented many people from being tested for fear of discrimination.³³

The innovative scheme also planned for 3,600 community health workers to be trained in HIV testing and counselling. These counsellors would approach every single household with rapid HIV tests. Everyone tested and counselled would then be referred to post-test services according to their HIV status. The plan relied on communities to choose how testing and counselling should be progressively rolled out.³⁴

Unfortunately by October 2006, the testing campaign had only recruited 720 community volunteers. Communities and local health centres needed much more time than was expected to mobilize resources for the programme. The World Health Organisation, the Global Fund and the United Nations Development Programme have provided financial support; however conditions of poverty and rural isolation, where many of the population can only be reached on foot or by horseback, hinder efforts to roll out local services. Lesotho’s lack of healthcare workers has proved a further obstacle to the testing campaign.³⁵

Treatment

Antiretroviral therapy has been available in Lesotho since 2001, initially through the Christian Health Association of Lesotho for the few that could afford it. The government launched its national programme to provide free antiretroviral therapy in November 2004, and by December 2005 around 8,400 people were receiving treatment.³⁶

The WHO’s initiative to treat 3 million people for HIV worldwide set the target for Lesotho to treat 27,000 people by 2005, or an estimated half of those who needed it. This was not achieved, and was put back to 2006.³⁷ Still, by December 2006 only 18,000 people were able to access treatment.³⁸

Lesotho's attempts to provide national antiretroviral treatment have been held back by huge shortages in healthcare staff. Not only do skilled medical professionals seek higher pay abroad, but HIV/AIDS has also taken its toll on Lesotho’s healthcare workers.³⁹ Only six of 171 health centres in the country have the minimum staffing required. Nationally there are just 89 doctors, and the number of employed nurses fell by 15% from 1994 to 2004.⁴⁰

In 2005 the “Expert Patient Scheme” was launched to tackle Lesotho’s health worker shortage. By October 2006 there were ten Expert Patients in Lesotho- HIV positive volunteers who use their experience of living with HIV and taking antiretroviral medication to help healthcare staff and counsel those accessing services. If the scheme proves a success and additional funding can be found, the programme could roll out to clinics nationwide and even provide a model for other countries in the region to manage similar health worker shortages.⁴¹

Care for Orphans

The number of AIDS orphans in Lesotho is rapidly increasing. Many children have lost one or both parents to AIDS, and a large section of Lesotho’s younger generation face growing up without parental support. The numbers of safe houses and orphanages that take care of orphans too young or unable to fend for themselves, has increased dramatically, and have tended to be unregulated. This phenomenon can expose already vulnerable children to further trauma, abuse and neglect.⁴² England’s Prince Harry, and Prince Seeiso of Lesotho have set up the “Sentebale” charity, in support of Lesotho’s orphans. The charity funds projects that attempt to fill some of the gaps left by existing government and community based projects.⁴³

What next for Lesotho?

The government of Lesotho has shown a forward thinking and dynamic approach to combating the spread of HIV. Unfortunately plans have been set back by financial constraints, severe shortages of health workers and the logistical difficulty of reaching parts of the population in mountainous and isolated rural areas.

Nevertheless, with foreign funding and technical assistance, Lesotho may be able to strengthen local communities to implement services, and improve rights for women. These measures are desperately needed in order for Lesotho to reduce the number of people becoming HIV positive every day, and increase access to treatment and care for those living with HIV.

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