Lesotho has the third highest HIV prevalence in the world - just under one in four people in the country are living with HIV. Around 18,000 people died from AIDS in 2007 and 110,000 children have lost at least one parent to the epidemic.¹ Over half of the 260,000 adults living with HIV in Lesotho are women.²

“There are two types of people in Lesotho; those infected and those affected by HIV/AIDS”.³

The AIDS epidemic in Lesotho has had a devastating impact on the country. Crippling poverty combined with AIDS has caused average life expectancy to drop to 40 years for women and 41 for men.⁴ The impact on individuals, families and the whole nation is being felt as adults become too sick to work, and children orphaned by 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.⁵ In 2007, Keketso Sefeane, chief executive of the National AIDS Commission in Lesotho, said HIV/AIDS has the potential to "wipe out" the country.⁶

The 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 1987,⁷ and sentinel surveys were introduced by 1992 to monitor the spread of HIV every two years. However, up until the year 2000 surveys were inconsistent due to lack of funding and technical problems.⁸

By 1996 HIV prevalence had risen to an alarming 26% among pregnant women aged 20 to 24, from 3.9% in 1992.⁹

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.¹⁰

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.¹¹

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.¹²

In 2006 Lesotho passed the Legal Capacity of Married Person's Act, which provides equal status to married women.¹³ Under traditional customary law women lacked political, financial and social rights, which made it more difficult for them to resist demands for sex and negotiate safer sex practices. This therefore made them more vulnerable to HIV infection. It is hoped the passing of the law will change women's subordinate status in Lesotho’s traditional culture, and enable them to better protect themselves from HIV.

The current HIV and AIDS situation in Lesotho

Since 2005 there has been no significant change in Lesotho's national adult HIV prevalence.¹⁴ An estimated 62 new HIV infections and 50 deaths due to AIDS occur each day.¹⁵ Of those infected with HIV in Lesotho:

• almost 12,000 are children;
• an estimated 17% are aged 15-24;
• and around 56% of adults are women.¹⁶

Lesotho’s AIDS effort is now guided by the National AIDS Policy and Strategic Plan for 2006-2011.¹⁷ 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.¹⁸

Universal HIV testing in Lesotho

In March 2004, Lesotho’s government launched an ambitious voluntary counselling and testing campaign, which 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 stigma and discrimination that surrounds HIV and AIDS in Lesotho, which has prevented many people from being tested.¹⁹

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.²⁰

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.²¹

A Human Rights Watch report investigating the campaign found some major faults.²² Key areas of negligence were poor training and supervision of testing counsellors, failures in safeguarding human rights, and inconsistent links between testing and treatment centres. Accountability was directed at the government and WHO for not recognising and addressing the problem.²³ The report also claimed that only 2% of the target 1.3 million people were tested for HIV by August 2007 through the scheme.²⁴ However in 2007, Lesotho's Ministry of Health reported an increase in testing and counselling coverage from 2.7% in 2004 to 17.2% in 2007.²⁵ A reported 204 facilities were providing HIV testing and counselling in 2008 - a 25% increase from the previous year.²⁶

Lesotho's National HIV/AIDS Strategic Plan 2006-2011 now has a target of ensuring that by 2011, 80% of Basotho aged 12 years and above will know their HIV status.²⁷

HIV prevention in Lesotho

The government of Lesotho has implemented several HIV prevention strategies, including educational campaigns, work-based HIV prevention initiatives, the targeting of high-risk groups and prevention of mother-to-child transmission. An estimated $26.5 million was spent on HIV prevention between 2006-07.²⁸

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. Counsellors and HIV tests have been made available at all roadshow events.²⁹

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.

Around one in five 15-24 year old males and one in four 15-24 year old females have a comprehensive knowledge about AIDS.³⁰

Workplace prevention initiatives

In 2006 Lesotho's Labour Code was amended to include policies and standards in terms of HIV and AIDS management in the workplace.³¹ Lesotho has also developed national guidelines for the implementation of workplace HIV and AIDS education programmes.³² 

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.³³ 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. By the end of November 2007, around 17,000 workers had access to the complete ALAFA workplace HIV programme.³⁴ It is estimated that 1,850 lives could be saved every year with these interventions.³⁵

Condom Distribution

Since July 2001 low-priced male condoms have been supplied through community-based distribution systems. 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.³⁶

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.³⁷

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.³⁸ The 2002 Behavioural Surveillance survey found that knowledge about AIDS was particularly low amongst miners and taxi drivers.³⁹

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.⁴⁰

Prevention of mother-to-child transmission of HIV (PMTCT)

In recent years Lesotho has dramatically increased PMTCT services. In 2005 only 12 percent of pregnant HIV positive women were receiving antiretroviral drugs to prevent mother-to-child transmission.⁴¹ By 2007 this figure had increased to 32 percent⁴² and by the end of 2008 an estimated 57 percent of pregnant women were receiving the drugs.⁴³ The percentage of women who accepted an HIV test during pregnancy has also increased, due to the introduction of an 'opt-out' testing policy. In 2007 around 91 percent of pregnant women had an HIV test - an increase from just over half of pregnant women in 2005.⁴⁴

“Lesotho is a model in its achievements, particularly in the field of preventing mother to child transmission of HIV” - Michel Sidibé, UNAIDS Executive Director⁴⁵

Although these are significant acheivements, there is still much progress to be made. In Lesotho's National Strategic plan a target has been set to reduce mother-to-child transmission of HIV to 10 percent by the end of 2010.⁴⁶

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

Treatment for HIV in Lesotho

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.⁴⁷

Lesotho's attempts to provide national antiretroviral treatment have been held back by huge shortages in healthcare staff. In 2007 it was reported that there were only 89 doctors for the whole population, 80 percent of which were from other African countries.⁴⁸ Skilled medical professionals often travel abroad to seek higher wages, leaving a shortage of trained staff in the country.⁴⁹

The World Health Organization set a 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 2006.⁵⁰ By December 2007 only 22,000 people were able to access treatment.⁵¹

In recent years Lesotho has made significant progress in treatment scale-up. By the end of 2008, the number of people receiving antiretroviral drugs was double that of 2007.⁵² A total of 104 sites were providing antiretroviral therapy, which included sites in remote parts of the country.⁵³

Care for orphans

The number of AIDS orphans in Lesotho is rapidly increasing. Out of all countries with an HIV prevalence greater than 1 percent, Lesotho has the largest percentage of children who have lost one or both parents.⁵⁴ 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.⁵⁵ 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.⁵⁶

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 infected with HIV, and increase access to treatment and care for those living with the virus.

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References:

1. UNAIDS (2008) 'Report on the global AIDS epidemic'
2. UNAIDS (2008) 'Report on the global AIDS epidemic'
3. CARE Lesotho (2004, April) ‘Lesotho’s Strength is its People: A Rapid Appraisal of Home and Community Based Care’ p.5
4. CIA World Factbook (2009) 'Lesotho'
5. Government of Lesotho (2006, November) ‘National HIV and AIDS Policy’ p.22
6. Kaiser Foundation (2007, 22nd August) 'HIV/AIDS could 'wipe out' Lesotho, official says'
7. Government of Lesotho (2006, November) 'National HIV and AIDS Policy' p.24
8. LAPCA et al (2002) ‘HIV/AIDS Behavioural Surveillance Survey 2002’
9. Human Sciences Research Council (2004) ‘An Audit of HIV/AIDS policies in Botswana, Lesotho, Mozambique, South Africa, Swaziland and Zimbabwe’ p.8
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56. ‘Sentebale, Forget me Not: The Princes’ Fund for Lesotho’