HIV/AIDS in Lesotho constitutes a very serious threat to Basotho and to Lesotho's economic development. Since its initial detection in 1986, HIV/AIDS has spread at alarming rates in Lesotho. In 2000, King Letsie III declared HIV/AIDS a natural disaster. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS) in 2016, Lesotho's adult prevalence rate of 25% is the second highest in the world, following Eswatini.
HIV has affected the majority of the general population, while disproportionately affecting the rural, working-age population. The spread of HIV in Lesotho is compounded by cultural practices, serodiscordancy, and gender-based violence. Lack of developed sexual education programs in schools places the young demographic at increased risk of HIV infection.
Over the past three decades, the Government of Lesotho, in collaboration with global organizations such as The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), World Health Organization (WHO), and President's Emergency Plan for AIDS Relief (PEPFAR), has dramatically improved HIV testing and treatment coverage through comprehensive program implementation. However, high levels of poverty, inequality, and stigma towards HIV remain major barriers to HIV prevention in Lesotho. As such, Lesotho seeks financial aid and guidance in program reform from its neighbor South Africa, which, despite having the highest number of people living with HIV in the world,The Joint United Nations Programme on HIV/AIDS (UNAIDS). 2017. Ending AIDS: Progress Towards 90-90-90. Report. Geneva: UNAIDS. has dramatically reduced costs of HIV prevention efforts in the past decade.Barton-Knott, Sophie. June 2013. Around 10 million people living with HIV now have access to antiretroviral treatment. Press Report. Geneva: The Joint United Nations Programme on HIV/AIDS (UNAIDS).
Prevalence
Lesotho's adult prevalence rate of 25% has remained relatively constant since 2005. In 2016, there was an estimated 330,000 people living with HIV as compared to 240,000 people in 2005, and 270,000 people in 2010. Overall, HIV incidence is declining, from 30,000 new infections in 2005 to an estimated 21,000 new infections of HIV in 2016.UNAIDS. UNAIDS Data 2017, 2017, pp. 32. Joint United Nations Programme on HIV/AIDS.
By sex
According to the 2014 Lesotho Demographic and Health Survey (LDHS), prevalence among women has increased from 26% in 2004 to 30% in 2014, whereas male HIV prevalence has stagnated around 19% over the same time period.Ministry of Health [Lesotho] and ICF International. Lesotho Demographic and Health Survey 2014, 2006, pp. 1–538. Maseru, Lesotho: Ministry of Health and ICF International. In 2014, Lesotho's Ministry of Health and Social Welfare (MOHSW) determined the prevalence rate among young women was 10.2%, whereas among young men it was 5.9%.Lesotho Ministry of Health and Social Welfare (MOHSW) “Global AIDS Response Country Progress Report: January -December 2014.” 2015, pp. 1–36, UNAIDS.
In 2015, pregnant women had a prevalence rate of 25.9%. Men who have sex with men (MSM) had a 32.9% prevalence rate in 2016.
By age
According to the 2003 HIV Sentinel Survey Report, the 25–29 age group was most affected by HIV, with prevalence of 39.1%. For the 15–19 and 20–24 age groups, median prevalence was 14.4% and 30.1%, respectively.Bowsky, Sara. US Government Rapid Appraisal for HIV/AIDS Program Expansion: Lesotho. Report. 2004. Accessed November 25, 2017. . In 2014, LDHS found that 13% of young women and 6% of young men ages 15–24 were infected with HIV.
In 2003, the Ministry of Health estimated that there were around 100,000 children under the age of 15 in Lesotho's 10 districts who had lost one or both parents to AIDS.
By occupation
Sex workers and factory workers are disproportionately affected by HIV, with prevalence rates of 79.1% and 42.7% in 2015, respectively.
Prison inmates constitute another key affected population, with a prevalence rate of 32.9% in 2015.
National response
The government of Lesotho has taken concrete actions to address the epidemic since King Letsie III's declaration of HIV/AIDS as a national emergency. Establishment of the National AIDS Prevention and Control Program and the Lesotho AIDS Programme Coordinating Authority (LAPCA) under the Prime Minister’s Office accelerated national and international response to the epidemic.
1980–2000
Lesotho's National AIDS Prevention and Control Program was formed in 1987.Bulled, Nicola. Prescribing HIV Prevention: Bringing Culture into Global Health Communication. Vol. 1. N.p.: Left Coast Press, 2015. Print. However, funding and infrastructural limitations prompted the United Nations to intervene in 1992 and assist with release of sentinel surveys to monitor the spread of HIV. As such, data collection remained inconsistent until 2000. It was not until 2004 that LDHS included HIV testing data to assess magnitude and patterns of HIV infection.
2000–2010
LAPCA was established in 2001 to coordinate the multisectoral response to HIV/AIDS, but several factors hindered it in fulfilling its strategic role. In October 2003, the government used Turning a Crisis into an Opportunity, a document constructed by a Lesotho-based United Nations interagency group, as an official working model to address the epidemic. In 2005, the government passed a bill establishing the semi-autonomous National AIDS Commission (NAC) and National AIDS Secretariat (NAS) to coordinate and support strategies for the period 2005 to 2008.National AIDS Commission, Lesotho. COORDINATION FRAMEWORK FOR THE NATIONAL RESPONSE TO HIV AND AIDS. Publication. 2007. Accessed November 25, 2017. http://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---ilo_aids/documents/legaldocument/wcms_126753.pdf.Lesotho committed itself to the World Health Organization (WHO) goal of having 28,000 people on antiretroviral therapy (ART) by the end of 2005. In May 2004, the first comprehensive HIV/AIDS center to provide ART opened. The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), international private organizations, local and international nongovernmental organizations (NGOs), and community-based organizations (CBOs) provided the mainstay of the response to HIV/AIDS, especially in the area of community mobilization. Most of these operations were small and localized to specific geographical areas in urban centers. The biggest challenge was the establishment of national networks and civil society organizations on HIV/AIDS, most importantly among people living with HIV/AIDS and within the NGO network. In 2005, the apparel and textile industry, Lesotho's biggest private employer, established an innovative sector-wide and comprehensive HIV workplace program through a public private partnership with the government of Lesotho, buyers, employers, and other donors.Overseas Development Institute. Aid for Trade in Lesotho: ComMark’s Lesotho Textile and Apparel Sector Programme. Publication. 2009. Accessed November 25, 2017. https://www.odi.org/sites/odi.org.uk/files/odi-assets/publications-opinion-files/5948.pdf . In May 2009, the Apparel Lesotho Alliance to fight AIDS (ALAFA) provided close to 90% of the 42,000 employees with prevention services, and up to 80% with treatment services."Apparel Lesotho Alliance to Fight Aids (ALAFA) Project." DAI: International Development. Accessed November 25, 2017. https://www.dai.com/our-work/projects/lesotho-apparel-lesotho-alliance-fight-aids-alafa-project. Lesotho has increasingly used community mobilization and education, as well as offering HIV testing and counseling (HTC) upon individual request. The burden of determining how and when people access treatment and counseling services is placed on local communities. Communities are responsible to ensure confidentiality and provide access to post-test services. In 2004, only 2.7% of Basotho adults participated in HTC. However, HTC participation increased to 35% by 2011.
2010–present
In 2014, the Ministry of Health initiated a new program involving provider-initiated testing and counseling, where providers traveled to homes providing HTC services instead of through individual request. However, lack of staffing and HIV test kit shortages severely impacted the program's effectiveness. A research study conducted by Labhardt et al. (2014) examined the relative merits of home-based versus mobile clinic HTC services, finding that mobile clinics were more effective at detecting new HIV infections, whereas home clinics were more effective for testing those who were getting tested for the first time.Labhardt, N.D. et al. (2014). Home-Based Versus Mobile Clinic HIV Testing and Counseling in Rural Lesotho: A Cluster-Randomized Trial. PLOS Medicine. In 2014, 63% of Basotho men and 84% of Basotho women had been tested for HIV at least once in their life, according to LDHS.
Other HIV prevention efforts spearheaded by Lesotho's Ministry of Health include preventing mother-to-child transmission (PMTCT) programs, voluntary medical male circumcision (VMMC), and condom distribution.Prevention Gap Report 2016. Report. UNAIDS, 2017. Accessed November 25, 2017. http://www.unaids.org/sites/default/files/media_asset/2016-prevention-gap-report_en.pdf.
In 2011, the Ministry of Health successfully launched the VMMC program. By 2012, 10,400 men had undergone VMMC; by 2014, around 36,200 men had undergone treatment. VMMC is most prevalent and effective among the 15–19 age group. VMMC program expansion is most hindered in rural areas, where traditional initiation rituals promote circumcision of young boys.
PMTCT efforts include ART for infected women throughout pregnancy, and HIV medication for babies 4–6 weeks after birth. In some cases, mothers will undergo cesarean deliveries to further prevent MTCT. In 2010, WHO recommended providing ART to all pregnant women regardless of CD4 count or viral load, causing the Ministry of Health to revise its PMTCT program accordingly.Lesotho Ministry of Health and Social Welfare (MOHSW) “Global AIDS Response Country Progress Report: January 2010 – December 2011.” 2012, pp. 1–106, UNAIDS, http://www.unaids.org/sites/default/files/country/documents//file,68395,fr..pdf As a direct result, the number of infected pregnant women receiving ART increased significantly from 58% in 2009 to 89% in 2012. However, staffing and funding challenges have compromised this program's effectiveness. In 2016, UNAIDS reported only 66% coverage among pregnant women.
The Ministry of Health proposed a HIV prevention strategy aimed to eliminate MTCT and reduce sexual transmission of HIV by 50% by 2015. MTCT is considered eliminated when transmission rate drops below 5%, according to UNAIDS. Data from Lesotho's 2015 UNAIDS Report indicates neither target was reached. In 2012, MTCT rates in Lesotho stagnated around 3.5%, but subsequently increased to 5.9% in 2014.
In 2015, the National Aids Commission (NAC) of Lesotho reported a distribution of 31 condoms per adult man, exceeding the United Nations Population Fund’s average of 30. Male condom use with sex workers has increased from 64% in 2009 to 90% in 2014. Additionally, in 2016, UNAIDS reported that 76% of adults aged 15–49 with more than one sexual partner in the past year used condoms.
In June 2016, the Ministry of Health launched the “Test and Treat” initiative, where every person tested HIV positive is offered ART, regardless of CD4 count. Lesotho is the first country in sub-Saharan Africa to implement this program.
Risk factors
There are various factors that place Basotho at increased risk for HIV contraction.
Cultural practices