Lesotho is one of the world’s countries hardest hit by HIV, with the second highest HIV prevalence after Swaziland.1 HIV prevalence was 22.9% in 2013, which has risen slightly from 22% in 2005.1 An estimated 360,000 people are living with HIV in Lesotho and 16,000 died from AIDS-related illnesses in 2013.2 HIV incidence has declined marginally from 30,000 new infections in 2005 to 26,000 new infections in 2013.1
Lesotho is a small country with a population of just over two million.3 High levels of poverty and inequality2 due to a struggling economy has left the country highly dependent on donors for financial support.4 Crippling poverty and HIV and AIDS has led to the country’s low life expectancy of just 49 years.3 This has resulted in a slow response to the HIV epidemic; although progress in some areas has been made, 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 (MSM).
Women and HIV in Lesotho
Women are disproportionately affected by HIV and AIDS in Lesotho. Inequality in HIV prevalence begins early in life, with HIV almost twice as prevalent amongst young women (10.5%) than young men (5.8%) aged 15-24 years old.1 Gender-based violence has been found to a significant driver for the increased HIV prevalence among women.5 Lesotho, like many southern African countries, has a highly embedded patriarchal society, which normalises gender inequality, increasing the prevalence of gender-based violence. Studies have found that large proportions of men and women in southern Africa do not believe women have the right to refuse sex with a partner5, with 62.5% of men in Lesotho believing they have the right to threaten their wives if they refuse sex.2 One study in Lesotho found that 37.1% of women believe that there are valid reasons for men to beat their wives.2 Beliefs such as these limit a women’s power within relationships and increases their vulnerability to sexual violence and HIV.
Young people and HIV in Lesotho
10.5% of young women aged 15-24 and 5.8% of young men in Lesotho are living with HIV. Young people are significantly affected by the epidemic in Lesotho, and increasing efforts have been made to provide adequate youth-oriented support and services for 15-24 year olds across the country.1 A lack of knowledge and safe behaviours are key factors that need to be considered in Lesotho’s epidemic among this affected population. Despite an increase in the percentage of young people’s comprehensive HIV and AIDS knowledge, only 38.6% of young women and 28.7% of young men have comprehensive knowledge.2 Early sexual debut is also prevalent in Lesotho, with 22.1% of girls and 7.8% of boys engaging in sex for the first time before age 15.2
There has been an increased focus on young people in Lesotho’s national HIV response, with a specific youth component featuring in the behaviour change strategy of the national AIDS strategy. Alongside numerous NGOs, a variety of campaigns have been launched, successfully reaching 15-24 year olds across the country. In 2011, Kick 4 Life reached over 100,000 young people by utilising technology and sending text messages, spreading awareness and increasing HIV knowledge.2 Using various platforms such a social media is also becoming more popular for reaching young people, enabling a more youth-orientated HIV response.
Various HIV prevention programmes have been carried out across Lesotho to reduce HIV prevalence and reach young populations. Cash transfer programmes have been found to be an effective method of HIV prevention in Lesotho, particularly for young females.1
Children and orphans and HIV in Lesotho
HIV and AIDS have been found to be the major factor causing orphanhood in Lesotho.2 The HIV epidemic has reached great proportions that have altered family life for many young people in the country. There are an estimated 150,000 orphans due to HIV and AIDS in Lesotho.6 This results in many children in Lesotho becoming young carers, looking after older generations including grandparents.2 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 3,400 in 2013. Despite the reduction, HIV treatment coverage for children living with HIV remains low at around 15% for children aged 0-14 years. Progress has been made in decreasing the number of deaths among HIV-positive children under the age of five from 23% in 2009 to 18% in 2013.1
Prisoners and HIV in Lesotho
A further key affected population in Lesotho is prisoners. Research has found that within the prison system, 31.4% of male inmates are living with HIV. Both inmates and prison staff have an increased perceived vulnerability to HIV, with 76.7% of male and 61.6% of female inmates and 80.8% of male and 71.5% of female prison staff stating an increased risk of contracting HIV within the prison environment. Due to this increased perceived risk, HIV testing among these populations is relatively high, with over 80% testing for HIV in the last 12 months.2
Men who have sex with men (MSM) and HIV in Lesotho
Men who have sex with men (MSM) across southern Africa have an increased risk of HIV infection. In Lesotho, there is limited research on MSM, which has resulted in little understanding of the HIV epidemic among this population. One of the few studies on MSM in Lesotho found a higher prevalence of high-risk sexual practices compared to the general population, and engagement in sex with both men and women. The research found a self-reported HIV prevalence among MSM of 11.6%.
Furthermore, the study found that the majority of MSM in the study (76.2%) reported human rights abuses due to their sexual orientation. These human rights abuses included physical and verbal harassment and difficulty seeking healthcare.7
HIV testing and counselling (HTC) in Lesotho
HIV testing and counselling services have been steadily expanding across Lesotho, particularly at a community level.2 Testing and counselling coverage was only 2.7% in 2004, by 2011, 35% of adults had taken an HIV test.8
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.9 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.
HIV prevention programmes in Lesotho
The main targets for Lesotho’s HIV prevention strategy are to reduce sexual transmission of HIV by 50% and eliminate mother-to-child transmission by 2015. HIV prevention has taken a variety of forms in Lesotho, including PMTCT programmes, VMMC and condom distribution.2 Condom use remains especially low in Lesotho with significant variations between urban (69%) and rural (33%) areas.2
Prevention of mother-to-child transmission (PMTCT)
The PMTCT programme in Lesotho has made progress, with the overall mother-to-child-transmission (MTCT) rate decreasing from 27% in 2009 to 22% in 2013.1 There has been increasing awareness and knowledge on the importance of PMTCT in Lesotho.
In 2013, 16,000 pregnant women were living with HIV and 8,218 of those women were receiving antiretroviral treatment1, reflecting coverage of 53%. It is clear that Lesotho’s PMTCT programme still has progress to be made.
Lesotho revised their PMTCT programme in 2010, which included, based on WHO recommendations, providing antiretroviral treatment for all pregnant women regardless of their CD4 count or viral load.2 Despite the revision to the PMTCT guidelines, human resources and funding challenges prevail for the country to achieve 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." 10
In 2010, 40% of HIV service centres and providers ran out of rapid test kits and dried blood spot test kits.10 Alongside stock-outs, limited access to healthcare -particularly antenatal care for pregnant women - is hampering this programme.11
Voluntary medical male circumcision (VMMC)
Lesotho’s voluntary medical male circumcision (VMMC) programme was launched in 2011, promoting the importance of VMMC for HIV prevention. The roll-out of the programme has been steady with two health centres providing services in the Maseru region of Lesotho.2
Voluntary medical male circumcision in Lesotho has experienced challenges in scaling-up due to traditional methods of circumcision a common feature of Lesotho culture for boys growing up. Predominantly in rural areas of Lesotho, boys are more likely to be circumcised during initiation rituals. 51.6% of males aged 15-49 years are circumcised in Lesotho, the majority of these circumcisions taking place between the ages of 13-19 years.2
TB and HIV
80% of people living with HIV in Lesotho have tuberculosis (TB); this high TB-HIV comorbidity requires urgent attention within the country’s HIV response. Improvements in identifying and diagnosing TB in people living with HIV in Lesotho have been made, and enrolment of antiretroviral treatment for co-morbid HIV and TB patients has been improved. Enrolment has increased from 26.9% in 2009 to 39.8% in 2011.2
Antiretroviral treatment (ART) in Lesotho
The scale-up of antiretroviral treatment (ART) in Lesotho has been gradual, however coverage remains low with only 23% of people living with HIV receiving antiretroviral treatment.1 Antiretroviral coverage for children is even lower, with only 15% of HIV-positive children receiving treatment.1 Lesotho has tried to increase coverage of ART for children through a variety of methods including satellite pediatric antiretroviral treatment centres.2
HIV treatment in Lesotho also depends a lot on external donors to provide funding necessary to roll-out and scale-up treatment programmes. PEPFAR is one example of an external donor that has developed a partnership with Lesotho. In 2011, Lesotho received $91.7million for HIV programmes. Through PEPFAR funding, in 2011, 56,900 individuals received antiretroviral treatment and 173,400 people living with HIV received care and support services.12
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 HIV incidence.2
Lesotho’s main mode of HIV transmission is through heterosexual sexual intercourse.13 There are a number of cultural barriers to HIV prevention in Lesotho. The Demographic Health Survey 2009 found that concurrent and multiple partners is a common feature in Lesotho’s society. 6% of women and 21% of men have had more than two sexual partners in the last 12 months. Within these figures, condom use was: only 39% of females and 52% of men reported using a condom during their last sexual encounter.13
Transactional sex is also high in Lesotho, with 7% of men reporting ever paying for sexual intercourse, with only 61% of men who paid for sex using a condom.13 Both multiple and concurrent partnerships and transactional sex increase the transmission of HIV and a lack of condom use is increasing vulnerability to HIV. 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.2 Women especially in Lesotho experience barriers to accessing health care, with 72% unable to access health services at a community level. Factors affecting access to healthcare include insufficient funds to travel to health centres and a lack of drug supplies.2
The way forward
Lesotho has made progress in tackling the country’s HIV epidemic, with the PMTCT programme substantially reducing the MTCT rate.
Increasing effort have 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.
Despite the country making progress in many areas, Lesotho’s HIV response has been slow in other areas; specifically HIV treatment coverage for adults and children remains low. Securing funding for HIV programmes will be vital to ensuring increased coverage.
Furthermore, inclusion of key affected populations in Lesotho’s HIV strategies is crucial for reducing prevalence, alongside challenging the widespread gender inequality and disproportionate impact of the HIV epidemic on women.
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.14
- 1. a. b. c. d. e. f. g. h. i. j. k. UNAIDS (2014) 'The Gap Report'
- 2. a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. q. r. s. t. u. Lesotho Ministry of Health (2012) ‘Lesotho Global AIDS Response Country Progress Report'
- 3. a. b. The World Bank ‘Data: Lesotho’ [accessed May 2015]
- 4. Human Rights Watch (2008) ‘A Testing Challenge’
- 5. a. b. SAfAIDS ‘Policy Brief: Lesotho- Violence against Women and HIV: Upholding the Zero Agenda by moving towards a Protective Legal and Social environment for women’ [accessed May 2015]
- 6. UNAIDS ‘Lesotho’[accessed May 2015]
- 7. Baral, S. et al (2011) ‘A cross-sectional assessment of population demographics, HIV risks and human rights contexts among men who have sex with men in Lesotho’ Journal of the International AIDS Society 14:36
- 8. World Health Organisation (WHO) (2007) ‘WHO applauds Lesotho Prime Minister for leading universal voluntary HIV testing drive’
- 9. Labhardt, N.D. et al (2014) ‘Home-Based Versus Mobile Clinic HIV Testing and Counseling in Rural Lesotho: A Cluster-Randomized Trial’ PLOS Medicine
- 10. a. b. IRIN Africa (2013) ‘Pregnant, positive and on HIV treatment for life’
- 11. McDougal, L. et al (2012) ‘Lesotho’s Minimum PMTCT Package: lessons learned for combating vertical HIV transmission using co-packaged medicines’, Journal of the International AIDS Society 15(2):17326
- 12. PEPFAR ‘Partnership to Fight HIV/AIDS in Lesotho’ [accessed May 2015]
- 13. a. b. c. Ministry of Health and Social Welfare (2010) ‘Lesotho Demographic Health Survey 2009’
- 14. UNDP (2014) ‘UN report: HIV prevalence severely impacting development progress’