Women and HIV in Lesotho
Women are disproportionately affected by HIV and AIDS in Lesotho. In 2016, HIV prevalence among women stood at 30% compared to 20% among men.
Lesotho, like many southern African countries, has a highly embedded patriarchal society, which normalises gender inequality, increasing the prevalence of gender-based and sexual violence, and heightening women’s risk to HIV.
Studies have found that 28% of young men and 27% of young women in southern Africa do not believe a woman has the right to refuse sex with a partner. A 2012 survey found 62.5% of men in Lesotho expressed the belief that they have the right to threaten their wives if they refuse sex. Beliefs such as these limit women's power within relationships and increase their vulnerability to sexual violence and HIV.
Preliminary results of a population-wide household survey in 2017 found HIV prevalence among women who had been physically forced to have sex stood at 39.3% compared to 31% among women who had not.
Lower condom use among women, compared to men, also increases their risk of HIV. In the Lesotho Demographic and Health Survey 2014 (LDHS 2014), 54% of women (compared to 65% of men) who had more than two sexual partners in the last 12 months reported using a condom during their most recent sexual intercourse. This may be due to a number of reasons including lack of access to condoms, and an inability to negotiate condom use with a male partner.
Young people and HIV in Lesotho
Young people are significantly affected by the epidemic in Lesotho. The Lesotho Demographic Health Survey conducted in 2014, found that 13% of young women and 6% of young men (aged 15-24) were living with HIV. Prevalence has increased among young women since 2009 when it stood at 10.5%, but has remained stable among young men.
Increasing efforts have been made to provide adequate youth-oriented support and services across the country. Despite the proportion of young people with comprehensive HIV and AIDS knowledge increasing in recent years, still only 37.6% of young women and 30.9% of young men could demonstrate comprehensive knowledge in 2014. In the same year, 6% of women and 12% of men reported engaging in sex for the first time before the age of 15.
In Lesotho, 8% of young women (age 15-19) had sex with a man 10 or more years older than them, compared to 1% of young men of the same age. This can contribute to the spread of HIV as the sexually experienced older partner is more likely to be living with HIV, heightening the younger partner’s risk of becoming infected.
Female sex workers and HIV in Lesotho
Although data is limited, HIV prevalence among female sex workers in Lesotho is thought to be extremely high, estimated at 71.9% in 2013/4.
Many female sex workers report experiences of sexual violence and harassment including rape and physical aggression. Many had also experienced police harassment and are too afraid to access health services.
A 2014 Ministry of Health study conducted in Maseru and Maputsoe found 55% of female sex workers in Maseru and 68% in Maputsoe had tested for HIV at least once. Condom use is estimated at 65%.
Men who have sex with men (MSM) and HIV in Lesotho
In Lesotho, there is limited research on men who have sex with men (sometimes referred to as MSM), which has resulted in little understanding of the HIV epidemic among this population. HIV prevalence is estimated at 33%.
In 2010, it was estimated that men who have sex with men accounted for roughly 3-4% of new annual HIV infections.
Recent data on men who have sex with men from two urban areas, Maseru and Maputsoe, found that only 56% of men in Maseru and 61% of men in Maputsoe had tested for HIV at least once. Condom use is estimated at 62%.
Many respondents in the Maseru and Maputsoe study reported experiencing stigma and human rights abuses, particularly verbal abuse, blackmail and physical aggression. Many were too afraid to access health services because of these experiences.
Children, orphans and HIV in Lesotho
HIV prevalence among children (ages 0 to 14) in Lesotho was estimated at 2.1% in 2016 (2.6% among girls and 1.5% among boys). HIV treatment coverage for children is improving and stood at 56% in 2015. However, this is still far below recommended coverage levels.
mother-to-child transmission (PMTCT) has had a significant impact in reducing new HIV infections, from 4,400 new child infections in 2009 to 1,300 in 2015. Progress has also been made in decreasing the number of deaths among HIV-positive children under the age of five from 860 in 2004 to 260 in 2014.
HIV and AIDS remains the biggest reason for children becoming orphaned in Lesotho. The HIV epidemic has reached great proportions that have altered family life for many young people in the country.
There are an estimated 73,000 orphans due to HIV and AIDS in Lesotho. This results in many children in Lesotho becoming young carers, looking after older generations including grandparents. This has implications for school attendance and also can increase poverty levels.
Prisoners and HIV in Lesotho
Prisoners are also more affected by HIV than the general population of Lesotho. Research conducted in 2012 found a third (31.4%) of male inmates were living with HIV. Interestingly, 76.7% of male and 61.6% of female inmates and 80.8% of male and 71.5% of female prison staff surveyed saw themselves as having an increased risk of contracting HIV within the prison environment. Due to this increased perceived risk, HIV testing among this group is relatively high, with over 80% of those questioned testing for HIV in the last 12 months.
Lesotho is one of only two countries in Southern Africa implementing condom programmes in prisons, the other being South Africa. Although there is some opposition to this in the country, the Minister of Justice and Correctional Service commented:
‘My advice to you is, focus on breaking the chain of infection, focus on cutting the HIV web, avoid dwelling too much on morality and legal issues, as I said, do your level best to put public health in the fore front above all other issues that are likely to hinder progress towards the prevention of new HIV infections, both in prison and in the general public.’ - Vincent Malebo, Minister of Justice and Correctional Service in Lesotho.
HIV testing and counselling (HTC) services have been steadily expanding across Lesotho, particularly at a community level. In 2016, 72% of people living with HIV in Lesotho had tested for HIV and were aware of their status. This is a major increase from 2004 when testing and counselling coverage was only 2.7%.
Testing coverage is generally higher among women than men in Lesotho. In 2014, 36.4% adult men and 58% of adult women (between the ages of 14-49) had taken an HIV test in the past 12 months and knew their results.
A recent study in Lesotho explored differences in uptake between mobile clinic HTC and home-based HTC services. The study found that the success of different services depended on which groups they were aiming to reach. Mobile clinics were more effective at detecting new infections, while home-based HIV testing were able to reach more children and people who had never tested before. Utilising information found in this study will be important for trying to engage more people in HIV testing, especially marginalised groups.
In 2014, Lesotho implemented provider initiated testing and counselling, which is when service providers offer HTC rather than waiting for an individual to request it. However, this has been compromised by a lack of health staff.
PEPFAR estimates that approximately 400,000 of the 700,000 people who visit health facilities annually are tested for HIV. Community-based testing accounts for a relatively small percentage (10-15%) of new diagnoses, however a large proportion of these diagnoses are among populations that are less likely to access health facilities such as men who have sex with men.
As in many countries, stigmatising beliefs about HIV and associated fears of discrimination are pervasive in the country and are one of the main barriers to HIV testing. Men are less likely than women to test, due in part to the fact that many women are tested through preventing mother to child transmission services.
Although Lesotho has a policy allowing HIV self-testing, it has not been implemented outside of research. In a 2015 study, 75% of participants who were offered a self test took it up, 14% of whom were newly diagnosed with HIV.
Case study: HIV services and sexual health in Lesotho
PB is an organisation that aims to engage young people between the ages of 15 and 24 in sexual health information and services. They train community-based volunteers – usually older, respected and approachable members of the community – to run youth groups linked to clinics, debates and camps engaging parents about sexual health in the Leribe district.
The volunteers have been instrumental in increasing demand and uptake of testing among adolescents and young people, and creating a more conducive environment for testing. Positive impacts include 6,622 young people testing for HIV, a reduction in teenage pregnancies in one school and increased confidence among the lesbian, gay, bisexual and transgender community, whose members feel better treated and more empowered to tell their stories.
In 2016, 21,000 people in Lesotho were newly infected with HIV. The vast majority of these infections (19,000) occurred among adults, 10,000 of whom were women.,
Lesotho takes a combination approach to HIV prevention. Its current prevention strategy aims to reduce sexual transmission of HIV by 50% and eliminate mother-to-child transmission (MTCT) by the end of 2018. These targets were initially set for 2015, and although adult HIV incidence declined by 29% between 2001 and 2014, this was not a rapid enough decline to meet the original deadline.
Condom availability and use in Lesotho
Lesotho’s National AIDS Commission (NAC) distributed 31 condoms per adult man in 2015, above the United Nations Population Fund’s regional benchmark of 30. Condom use among adults aged 15-49 with more than one sexual partner in the past 12 months was reported as 76% in 2016.
There has been an increase in condom use among men who pay for sex, with 90% reporting condom use with a sex worker in 2014, compared to 64% in 2009.
HIV education and approach to sex education in Lesotho
Lesotho’s national AIDS strategy contains a specific youth component as part of its behaviour change strategy. This has led to a variety of HIV awareness campaigns aimed at 15-24 year olds across the country. For example, the Kick 4 Life campaign, which uses football to bring HIV prevention messages to young people, had enabled more than 100,000 participants to access health education and life skills activities and connected 25,000 young people to HIV testing.
Various communication platforms such as television and social media are also being utilised. For example, television drama Kheto ea ka! (Your Choice) has been produced by Lesotho’s Ministry of Health and Social Welfare and NAC, in collaboration with behaviour change organisation Mantsoapo, to target students with messages of HIV risk and prevention. Cash transfer programmes have also been found to be an effective method of HIV prevention in Lesotho, particularly for young women.
Prevention of mother-to-child transmission (PMTCT)
Lesotho revised its PMTCT programme in 2010 in line with World Health Organization (WHO) recommendations to provide ART for all pregnant women regardless of their CD4 count or viral load. Despite the revision to the PMTCT guidelines and progress being made on the proportion of pregnant women receiving ART, human resources and funding challenges continue to prevent Lesotho from achieving this.
UNAIDS considers HIV transmission from mother to child to be eliminated when the transmission rate drops below 5%. While Lesotho’s mother to child transmission (MTCT) rate stood at 3.5% in 2012, progress has now reversed with MTCT standing at 5.9% in 2014.
In 2016, among pregnant women who were living with HIV around 66% were receiving antiretroviral treatment (ART). Although this is an improvement from 58% in 2009, coverage has been declining in recent years as it stood at 89% in 2012.
Case study: Pre-conception support for couples living with HIV
Senkatana, an ART clinic treating more than 4,000 women living with HIV, began offering integrated sexual and reproductive health services in 2012, responding to the need for reproductive health services from half of its patients and aiming to reduce mother-to child transmission.
Couples who wanted to have children had their CD4 counts and viral load closely monitored, receiving folic acid and multivitamins. From more than 250 tests on children born to HIV-positive mothers between 2012 and 2015, none were found to have the virus.
Voluntary medical male circumcision (VMMC)
VMMC is a key strategy for primary prevention of HIV infection in Lesotho. However, implementing it has been challenging in rural areas, where boys are more likely to be circumcised during initiation rituals.
Despite this, significant progress has been made. Lesotho’s prevention strategy includes a target to circumcise 80% of all men aged 15-49 by 2020. As of 2016, 72% of men of this age group were circumcised.
The number of circumcisions carried out in 2016 stood at 34,157. This is an improvement on 2015 levels when VMMC was found to be declining.
In 2014, around 56% of men who came for VMMC were tested for HIV and received the results. Most men who accessed these services were aged 15 to 19. The mean HIV prevalence among those who were tested was 4%.
Pre-exposure prophylaxis (PrEP )
pre-exposure prophylaxis (PrEP), is a course of HIV drugs taken daily by HIV-negative people most at risk of HIV to reduce their risk of infection.
Truvada, a common form of PrEP, is registered and approved for use in Lesotho. The country’s 2016 antiretroviral guidelines recommend the use of PrEP as a prevention method for people at high risk of HIV.
However, PrEP is not widely available, with around 800 people estimated to be using it in 2017. A number of international donors are funding PrEP programmes in Lesotho to increase access. A large-scale implementation project supported by the President’s Emergency Plan For AIDS Reduction (PEPFAR) aims to reach just under 24,000 at risk people by 2017, while Anova Health Institute’s Health4Men Initiative is running a smaller demonstration PrEP project, targeting 300 men who have sex with men.
Antiretroviral treatment (ART) coverage in Lesotho has been increasing in recent years, and in 2016 53% of adults were accessing treatment. This equates to 168,000 people living with HIV.
In June 2016, Lesotho became the first African country to implement a 'Test and Treat' strategy. This means every person who tests HIV positive will be offered ART regardless of their CD4 count. By 2018, Lesotho aims to enrol at least 80% of all people living with HIV on treatment, and hopes to retain 85% of these people on treatment for at least 12 months.
Around 60% of women living with HIV were on treatment in 2016, compared to just 43% of men living with HIV. As in many countries, masculine gender norms make it more challenging for men than women to take an HIV test or feel comfortable accessing or adhering to treatment.
There is a similar gap between men and women in terms of viral suppression rates. A 2016/17 national survey reported the viral suppression among adults (15-59 years) living with HIV to be 70.5% among women compared to 63.4% among men. Overall, viral suppression among adults living with HIV stands at 67.6%.
According to Lesotho’s 2015 UNAIDS Progress Report, the proportion of people retained on ART after 12 months ranges between 70% and 80%.
ART coverage for children has also improved and now stands at 56%. Lesotho has increased coverage of ART for children through a variety of methods including satellite paediatric ART centres, which are able to provide services to children living in remote areas.
HIV drug resistance is of increasing concern in Lesotho. Data from 2009 suggests that just under 5% of HIV transmitted in a given sample was already resistant to non-neucleotide reverse transcript inhibitors (NNTRI) drugs and 5% was resistant protease inhibitor (PI) drugs. Because the country has such high rates of HIV it has been chosen as one of the focus countries for the World Health Organization’s (WHO) Global action Plan on HIV drug resistance.
Civil society in Lesotho works against a backdrop of political instability.
A variety of civil society organisations (CSOs) exist in Lesotho, representing a wide range of groups including women, children, young people, and people who are lesbian, gay, bisexual, transgender or intersex (LGBTI). Most of these groups are part of the Lesotho Council of NGOs, an umbrella organisation that provides NGOs with support as well as representation when dealing with the government. In general, Lesotho's CSOs enjoy constitutional freedoms and are free from interference yet have limited opportunities to engage with parliament.
Men who have sex with men and people who are LGBTI continue to face widespread exclusion and violence, which can disrupt the efforts of CSOs working with, or led by, people from these population groups. Civil society has called for the establishment of a national human rights institution. Although a Bill to introduce such a body was approved in 2014 it is yet to happen.
“Gay rights are human rights. We do not advocate special gay or lesbian rights. We want to be respected for who we are.” - Monaheng Khoele, programme manager at Matrix Support Group, an organisation for LGBTI people in Lesotho.
In 2014, 74% of people living with tuberculosis (TB) in Lesotho tested positive for HIV. Improvements in identifying and diagnosing TB in people living with HIV in Lesotho have been made with 93% of people with TB testing for HIV in 2014, compared to 82% in 2011.
Enrolment on ART for people with both TB and HIV has also improved, increasing from 26.9% in 2009 to 72% in 2014. Despite, this in 2016 5,200 of the AIDS-related deaths in Lesotho were due to TB.
Socio-economic barriers to healthcare
Lesotho has a number of HIV programmes operating across the country but many people struggle to access these services. Access to healthcare in Lesotho varies greatly by gender, socio-economic status and geography. Factors affecting access to healthcare include insufficient funds to travel to health centres, so people often run out of ARVs without being able to get more. The Lesotho Demographic and Health Survey 2014 found 38% of rural respondents had to walk for more than two hours to their nearest health facility compared to around 3% of urban respondents.
HIV-related stigma and discrimination
HIV stigma and discrimination remain major barriers to accessing vital HIV treatment, prevention and support services.
However, LDHS 2014 found attitudes towards people living with HIV to have improved slightly. In 2009, 42% of women and 33% of men expressed fully accepting attitudes to people living with HIV, compared with 46% of women and 36% of men in 2014.
The People Living with HIV Stigma Index Report found 4% of people living with HIV had been denied access to healthcare services over the previous 12 months. Over the same period, 5.6 % and 5.5% were denied family planning and sexual reproductive health services respectively. These results show how stigma can prevent people living with HIV in Lesotho from accessing their right to health.
Legal barriers to healthcare
There is uncertain and conflicting evidence on Lesotho’s legal environment for LGBTI people. Some sources cite a change to the law in 2012, removing explicit mention of sodomy as a punishable act, as effectively decriminalising same-sex sexual relations (amongst consenting adult males), whereas others argue that the act of sodomy is still prohibited as a common-law offence. What is clear is that the law in Lesotho does not contain an anti-discrimination provision to protect people from being discriminated against on the basis of their sexual orientation and/or gender identity.
The legal confusion, coupled by entrenched social attitudes towards homosexuality, results in a situation where men who have sex with men, and people who are LGBTI face discriminatory attitudes about their sexual orientation or/ gender identity. A survey carried out among LGBTI people in Lesotho found the majority (76.2%) had experienced human rights abuses, and more than half (59.8%) have been verbally or physically harassed because of it. These attitudes prevent many from accessing healthcare, including services for HIV prevention and treatment.
Data barriers relating to healthcare
Data systems are poor in Lesotho and limit the ability to measure the number of people living with HIV who are actively enrolled in treatment
Data systems are poor in Lesotho and limit the ability to measure the number of people living with HIV who are actively enrolled in treatment. Without a unique personal identifier and with a highly mobile population, it is challenging to track patients across the continuum of care (from testing, to treatment initiation and adherence, through to viral suppression). However, efforts to develop an electronic medical record have been largely unsuccessful.
Structural and resource barriers to healthcare
Resource barriers to healthcare in Lesotho are numerous and include low recruitment and retention of health staff, a lack of accurate and timely laboratory diagnosis and patient monitoring, and a lack of ownership and participation in service delivery by communities most affected by HIV. The National AIDS Commission (NAC) was disbanded in 2011, and although it was reformed in 2015, its absence disrupted the country’s HIV response during this time, the effects of which are still being felt.
Funding for HIV in Lesotho
In 2016, 29% of funding for Lesotho’s HIV response came domestically, from the Lesotho government, while 71% came from international sources. Government expenditure has increased by US$4 million between 2014/15 and 2016/17. Government funds cover just under half of the total costs of HIV treatment and care in Lesotho, the rest is made up by PEPFAR, the Global Fund and other sources.
Historically, the Global Fund, Lesotho’s government, and PEPFAR each funded about 30% of Lesotho’s HIV response. However, investments from the Global Fund are projected to decrease from US$34 million a year to US$22 million a year, starting in 2018 under the Global Fund’s transitional arrangement for middle-income countries. However, payments from PEPFAR are set to rise from US$39 million in 2015 to $81 million in 2017.
Available funding for Lesotho’s HIV programme for 2015-2018 is only half of the projected need of US $557 million. Lesotho’s Ministry of Health has increased its budget allocation for HIV and AIDS from 10% of national budget in 2014/15 to 16% in 2016/17 (an increase of US$4 million) but it is uncertain if it will meet the US$10.7 million increase it has committed to.
Controlling the HIV epidemic is not only critical for reducing HIV prevalence in Lesotho, but has also been described as fundamental for achieving other development-related goals.
Lesotho has made progress in tackling the country’s HIV epidemic, with its PMTCT programme substantially reducing the MTCT rate. However, the fact that some gains made in this area are now reversing is of concern.
Increasing effort has been made to include young people in HIV policy and programming, with more youth-oriented campaigns and strategies to reduce HIV prevalence among this population. VMMC coverage has also been widest in young men.
Given the high HIV prevalence of certain key affected populations, increasing inclusion of the needs of these groups in Lesotho’s future HIV strategy will be crucial for reducing HIV. In particular, the widespread gender inequality and disproportionate impact of the HIV epidemic on women, especially young women and female sex workers, must be further addressed.
HIV treatment coverage for adults and children has been improving and will hopefully increase further due to Lesotho’s adoption of test and treat. However, the issue of funding will largely dictate the effectiveness of this intervention. Securing funding to meet this need will be vital to ensuring hard won progress in Lesotho’s response to HIV is not reversed.