Crippling poverty and HIV and AIDS has led to the country’s low life expectancy of just 52 for men and 55 for women.
Lesotho is one of the countries hardest hit by HIV, with the second highest HIV prevalence after Swaziland.1 HIV prevalence was 22.7% in 2015, and has been around this level since 2005.2 An estimated 310,000 people were living with HIV in Lesotho and 18,000 died from AIDS-related illnesses in 2015.3. However, HIV incidence is declining, from 30,000 new infections in 2005 to 18,000 new infections in 2015.4 Lesotho is a small country with a population of just over two million.5 High levels of poverty and inequality6 due to a struggling economy have left the country highly dependent on donors for financial support.7
Crippling poverty and HIV and AIDS has led to the country’s low life expectancy of just 52 for men and 55 for women.8 This has resulted in a slow response to the HIV epidemic. Although progress has been made in some areas, challenges remain.
Key affected populations and HIV in Lesotho
There are a number of key affected populations in Lesotho. The Lesotho Global AIDS Response Country Progress Report highlights a number of these groups, including women and young girls, orphans and children, prison inmates and prison staff and men who have sex with men.
Women and HIV in Lesotho
Women are disproportionately affected by HIV and AIDS in Lesotho. Lesotho’s 2014 Demographic and Health Survey (LDHS) reports prevalence among women to have increased from 26% in 2004 to 30% in 2014, while prevalence among men has remained stable at 19% over the same period.9
Gender-based violence has been found to be a significant driver for the increased HIV prevalence among women.10 Lesotho, like many southern African countries, has a highly embedded patriarchal society, which normalises gender inequality, increasing the prevalence of gender-based violence. LDHS 2014 reported 33% of women and 40% of men expressing the belief that a husband is justified in beating his wife in certain circumstances.11
Other studies have found that large proportions of men and women in southern Africa do not believe a woman has the right to refuse sex with a partner.12. 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.13 Beliefs such as these limit women's power within relationships and increase their vulnerability to sexual violence and HIV.
The majority of garment factory workers in Lesotho are young women who often migrate from the rural areas towards the cities and industrial zones in search of work. The Garment Industry is based in the districts of Leribe and Maseru which have high HIV prevalence.14
The conditions under which the garment factory workers operate are often unfavourable and characterised by low pay and long working hours. This means that women factory workers are often unable to access healthcare services including sexual and reproductive health.15
Studies have also shown that the bulk of sex workers in the districts of Maseru and Leribe were originally garment workers who found sex work more lucrative in the light of low wages offered by the factories.16
Young people and HIV in Lesotho
Young people are significantly affected by the epidemic in Lesotho. LDHS 2014 found 13% of young women and 6% of young men (aged 15-24) were living with HIV. Prevalence has been rising among young women as it stood at 10.5% in the 2009 but has remained stable among young men.17
Increasing efforts have been made to provide adequate youth-oriented support and services across the country.18 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 2014.19 In the same year, 6% of women and 12% of men reported engaging in sex for the first time before the age of 15.20
A specific youth component now features in the behaviour change element of Lesotho’s national AIDS strategy. As part of this, a variety of campaigns have been launched to reach 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 reached over 250,000 15 to 24-year-olds as of 2016.21
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 its National AIDS Commission (NAC), in collaboration with behaviour change organisation Mantsoapo, to target students with messages of HIV risk and prevention.22 Cash transfer programmes have also been found to be an effective method of HIV prevention in Lesotho, particularly for young women.23
Case study: HIV services and sexual health in Lesotho
In a project aiming to help young people aged between approximately 15 and 24, Phelisanang Bophelong trains 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 in the first 15 months of the project have included tests for 3,286 people via 13 youth groups, 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.
Herd boys are among the most disadvantaged young people in Lesotho. Poverty encourages many to take up herding livestock as a full-time occupation, meaning many are deprived of formal education and lack access to health services, including HIV prevention, treatment and care.24
As of 2014, NGOs, in collaboration with the Ministry of Education, local government and local communities, have provided basic education to 550 herd boys from selected mountain areas. As part of this they received sexual and reproductive health information, and access to HIV testing and counselling. As a result, 800 herd boys and other community members were tested for HIV.25
Children, orphans and HIV in Lesotho
HIV and AIDS have been found to be the biggest reasons for children becoming orphaned in Lesotho.26 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.27 This results in many children in Lesotho becoming young carers, looking after older generations including grandparents.28 This has implications for school attendance and also can increase poverty levels.
Prevention of 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. HIV treatment coverage for children living with HIV has improved over recent years and stood at 56% in 2015. However, this is still far below recommended coverage levels.29 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 2014.30
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 virus31.
Prisoners and HIV in Lesotho
A further key affected population in Lesotho is prisoners. 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.32
Lesotho is one of only two countries in Southern Africa implementing condom programmes in prisons, the other being South Africa.33
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. However, Lesotho’s Ministry of Health included data in its UNAIDS Country Progress Report 2015 about men who have sex with men and female sex workers from two urban areas Maseru and Maputsoe. This found many of the men who have sex with men questioned had tested for HIV more than once (56% in Maseru and 61% in Maputsoe). It estimated HIV prevalence among this population to be 31% and 35% in Maseru and Maputsoe respectively, far surpassing national prevalence. Many respondents 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.34
Female sex workers and HIV in Lesotho
Similarly there is limited research on female sex workers in Lesotho, which has resulted in little understanding of the HIV epidemic among this population. However, the 2014 Ministry of Health study conducted in Maseru and Maputsoe mentioned above reveals some insight. The study found 55% of female sex workers in Maseru and 68% in Maputsoe had tested for HIV more than once.
HIV prevalence was found to be extremely high at 73% in Maseru and 70% in Maputsoe. Many female sex workers reported experiences of sexual violence and harassment including rape and physical aggression. Many had also experienced police harassment and were too afraid to access health services.35
HIV testing and counselling (HTC) in Lesotho
HIV testing and counselling (HTC) services have been steadily expanding across Lesotho, particularly at a community level.36 Testing and counselling coverage was only 2.7% in 2004, by 2011, 35% of adults had taken an HIV test.37 The 2014 LDHS found 63% men and 84% of women had ever tested for HIV. These are the highest testing rates ever recorded by in LDH surveys.38 In the same year, 51.8% of adults (aged 14-49) had taken an HIV test in the past 12 months and knew their results.39
A recent study in Lesotho explored the difference in HTC services, particularly mobile clinic HTC and home-based HTC services. The study found that the effectiveness of the type of HTC service depended on whom the HTC service was aiming to reach. Research found that mobile clinic HIV testing was more effective at detecting new infections, while home-based HIV testing was more appropriate for testing children and people who have never had an HIV test before.40 Utilising information found in this study will be important for trying to engage more people in HIV testing, promoting the importance and reaching 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.41 There were also frequent HIV test kit shortages in 2014. This was due to weak procurement systems rather than funding shortages. Efforts are now under way to strengthen human resourcing, forecasting and procurement systems to address these issues.42
HIV prevention programmes in Lesotho
HIV prevention has taken a variety of forms in Lesotho, including preventing mother to child transmission (PMTCT) programmes, voluntary medical male circumcision (VMMC) and condom distribution.43 Lesotho’s NAC distributed 31 condoms per adult man in 2015, above the United Nations Population Fund’s regional benchmark of 30.44 Condom use among adults aged 15-49 with more than one sexual partner in the past 12 months was reported as 60.9% in 2014.45
There has been an increase in condom use among men who paid for sex, with 90% reporting condom use with a sex worker in 2014 compared to 64% in 2009.46
The main targets for Lesotho’s HIV prevention strategy are to reduce sexual transmission of HIV by 50% and eliminate mother-to-child transmission (MTCT). These targets were set for 2015 but Lesotho’s 2015 UNAIDS Country Progress Report, which contains 2014 data, indicates the country is not on track to meet either target. Its 2014 national HIV estimates show that, although new infections are slowly declining, adult HIV incidence has only declined by 29% between 2001 and 2014.47
Prevention of mother-to-child transmission (PMTCT)
UNAIDS considers HIV transmission from mother to child to be eliminated when the transmission rate drops below 5%. While Lesotho’s MTCT rate stood at 3.5% in 2012, progress has now reversed with MTCT standing at 5.9% in 2014.48
In 2015, around 12,000 pregnant women were living with HIV, 72% (around 8,000) of whom were receiving antiretroviral treatment (ART).49. Although this is an improvement from 58% in 2009, coverage has been declining in recent years as it stood at 89% in 2012.50
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.51 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.
Changing guidelines is never easy as just switching the pills used- it involves the whole system. People tend to forget this when moving from one guideline to the other.52
Voluntary medical male circumcision (VMMC)
VMMC is a key strategy for primary prevention of HIV infection in Lesotho. The country’s VMMC programme launched in 2011 and by 2012 around 10,400 men had undergone VMMC. In 2014, the number of men receiving VMMC had roughly tripled to 36,200.53 However, the number of men accessing VMMC declined in 2015, according to the 2016 UNAIDS Global AIDS Progress Report. This reflects an overall downward trend across sub-Saharan Africa in 2015.54
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%.55
VMMC in Lesotho has experienced challenges in scaling-up due to traditional methods of circumcision, a common feature of Lesotho culture. Predominantly in rural areas of Lesotho, boys are more likely to be circumcised during initiation rituals.56
TB and HIV
In 2014, 74% people living with tuberculosis (TB) in Lesotho tested positive for HIV.57 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 2011.58
Enrolment on ART for people with both TB and HIV has also improved, increasing from 26.9% in 2009 to 72% in 2014.59
Antiretroviral treatment (ART) in Lesotho
The scale-up of ART in Lesotho has been increasing in recent years and stood at 41% of eligible adults in 2015. This equates to 45% of eligible women and 36% of eligible men living with HIV.60
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.63 This policy is in line with WHO guidelines released in September 2015.64
HIV care and treatment makes up the largest proportion of spending on HIV/AIDS in Lesotho. The Government of Lesotho funded 47% of treatment and care in 2015, with the Global Fund to Fight AIDS, Malaria and Tuberculosis funding 24%, PEPFAR funding 15% and other donors funding 14%.65
Barriers to HIV prevention programmes
Despite a number of HIV-related targets and strategies being developed within Lesotho’s HIV response, many barriers and challenges are impeding progress in HIV prevention.
Cultural and structural barriers have been identified by the government of Lesotho as obstacles to the response and need to be addressed effectively within HIV prevention programmes if Lesotho is to witness a reduction in new HIV infections.66
Lesotho’s main mode of HIV transmission is through heterosexual sex, accounting for 80% of new infections in 2014.67 A number of cultural barriers are driving this.
The 2014 LDHS found concurrent and multiple partners feature in Lesotho’s society. Of those surveyed, 7% of women and 27% of men have had more than two sexual partners in the last 12 months. Among these, 54% of women and 65% of men reported using a condom during their most recent sexual intercourse.68
Transactional sex, when sex is exchanged for goods, money or favours, is also high in Lesotho, with 11% of men reporting ever paying for sex, of whom 90% used a condom.69
In many societies, young women have sexual relationships with men who are considerably older than they are, which can contribute to the spread of HIV. 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.70
Addressing these cultural barriers in HIV prevention programmes is critical if Lesotho is to tackle the HIV epidemic effectively.
Access 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.71 Factors affecting access to healthcare include insufficient funds to travel to health centres and a lack of drug supplies. For example, the LDHS 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.
Around 28% of rural respondents had to walk between one and two hours, compared to 8% of urban respondents.72
HIV stigma and discrimination
Gossip, verbal as well as physical abuse and exclusion from social, religious and family gatherings or activities, were found to be the main forms of HIV-related stigma and discrimination. 41.1% of respondents experienced gossip about their HIV status, while 26.8% reported being verbally insulted, harassed and/or threatened.74
A total of 4% of people living with HIV were reported to have 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.75
Despite this, the 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 2014.76
The future of HIV and AIDS in Lesotho
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.77
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, although the decline of the VMMC rate in 2015 may indicate a slowdown in this area.
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.
Encouragingly, Lesotho has increased domestic funding for its HIV response in recent years. In 2015, 34% of funding came from domestic resources, compared to 26% in 2014. In 2016, Lesotho was expected to increase domestic funding by a further 57% in order to cover test and treat. Projections for 2017 and 2018 suggest domestic funding will continue to increase, by 5% and 2% respectively.78
However, between 2014/15 and 2017/18, the available financial resources for Lesotho’s HIV response is estimated to be US$344 million, which leaves a funding gap of US$249 million. At the same time, financial resources from international donors and other sources are projected to decline by 25% in total. This funding gap is most likely to have an impact on treatment.79 Securing funding to fill this gaps will be vital to ensuring hard won progress in Lesotho’s response to HIV is not reversed.
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