Final_Lesotho_HIV_Strategic_Plan_2018-2023_Signed.pdf

Government of Lesotho

National HIV & AIDS Strategic

Plan 2018/19 – 2022/23

Ending AIDS by 2030 i

TABLE OF CONTENTS

LIST OF TABLES ...................................................................................................................................................................... ii

LIST OF FIGURES .................................................................................................................................................................... ii

FOREWORD ............................................................................................................................................................................. iii

ACKNOWLEDGEMENTS ........................................................................................................................................................ iv

ABBREVIATIONS AND ACRONYMS ...................................................................................................................................... v

EXECUTIVE SUMMARY ......................................................................................................................................................... vii

1. CONTEXT AND RATIONALE FOR A NEW STRATEGIC PLAN

1.1 Introduction and Rationale

1.2 How this Plan was Developed

1.3 Operational and Socioeconomic Context

1.4 Health Systems

1.5 Human Rights, Law and Gender Context

2. EPIDEMIOLOGICAL TRENDS AND RESPONSE ANALYSIS

2.1 Epidemiological Trends

2.2 Sources of New Infections and Drivers of the Epidemic

2.2.1 Sources of New Infections by Population Characteristics

2.2.2 Drivers of the Epidemic

2.3 Response Analysis – Progress, Challenges and Opportunities from NSP (2011-2018)

2.3.1 Progress against Program Goals and 90-90-90 Targets

3. STRATEGIC FRAMEWORK FOR NSP 2018-2023

3.1 Overview

3.2 Program Result 1: 90% of people aged 15 and over at risk for HIV have accessed combination HIV prevention by

3.2.1 Result Area 1.1: Social and behaviour Change Communication and Transforming Harmful Socio-cultural Norms, Values, Beliefs and Practices

3.2.2 Result Area 1.2: Voluntary Medical Male Circumcision (VMMC)

3.2.3 Result Area 1.3: Comprehensive Condom Programming and Lubricants

3.2.4 Result Area 1.4: Pre-Exposure Prophylaxis

3.2.5 Result Area 1.5: Combination Prevention Packages for Key and Vulnerable Populations

3.2.6 Result Area 1.6: Prevention for Adolescent Girls and Young Women and their Male Partners

3.3 Program Result 2: Mother to Child Transmission Eliminated and 95% of children living with HIV on treatment by

3.3.1 Result Area 2.1: Mother to Child Transmission of HIV Eliminated by 2023

3.3.2 Result Area 2.2: 95% of children living with HIV on treatment by 2023

3.4 Program Result 3: Test and Treat Cascade Fast Tracked to attain 95-95-95 targets by 2023

3.4.1 Result Area 3.1: Differentiated and Enhanced HIV Testing Services

3.4.2 Result Area 3.2: Treatment, Care and Support

3.4.3 Result Area 3.3: TB HIV Collaboration

3.5 Program Result 4: Gender and Human Rights related barriers to service delivery, accessibility and utilization removed by 2023

3.5.1 Result Area 4.1: Removed legal, policy, religious and cultural barriers to HIV services

3.5.2 Result Area 4.2: Sexual and gender-based violence eradicated

3.6 Program Result 5: Strengthened national social and child protection systems to ensure 75% of PLHIV, and those at risk of and affected by HIV benefit from HIV-sensitive social protection by 2023

3.6.1 Result Area 5.1: HIV-Sensitive Social Protection availed to the most at risk and vulnerable populations to decrease vulnerability

3.7 Program Result 6: At least 40% of the HIV/TB response is community-led and sustainable by 2023

3.7.1 Result Area 6.1: Accountable, increasingly engaged and capacitated Civil Society Organizations

3.7.2 Result Area 6.2: Strengthened networks of people living with disease, key populations, adolescents and young women to plan, deliver, monitor and sustain interventions

3.7.3 Result Area 6.3: Strengthened and Resilient Community Systems

3.8 Program Result 7: Health System is people-centred, and sustainably integrates HIV, TB, Hepatitis and other infections by 2023

3.8.1 Result Area 7.1: Human Resources for Health

3.8.2 Result Area 7.2: Pharmaceutical Services

3.8.3 Result Area 7.3: Laboratory Systems

3.8.4 Result Area 7.4: Supply Chain Management

3.8.5 Result Area 7.5: Health Management Information Systems

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3.9 Program Result 8: Increased efficiencies and financial investments in HIV and TB programs to 90% of the NSP budget by 2023

3.9.1 Result Area 8.1: Expanded financing for HIV Response

3.9.2 Result Area 8.2: Sustainability of the response with increased domestic financing

3.9.3 Result Area 8.3: Increased Value for Money (Efficiency, Economy, Equity and Effectiveness)

4. MANAGEMENT AND COORDINATION

4.1 Coordination of the Strategy

4.2 Policy, Governance, Advocacy and Resource Mobilization Structures

4.3 Roles of Structures for the Response:

4.4 Roles of NAC under this NSP:

4.5 Public Sector Coordination and Roles of Government Ministries:

4.6 Coordination at District and Community Levels:

4.7 Coordination among Non-State Actors - at National, District and Community Levels

5. MONITORING AND EVALUATION

6. RESOURCE NEEDS ESTIMATES

6.1 Total Resources Needed

6.2 Analysis of Resource Needs for the HIV Response

ANNEXES

Annex 1 Results Framework Annex 2 Stakeholders Consulted

LIST OF TABLES

Table 1-1 Summary of Critical Demographic, Health and Economic Indicators Table 3-1 National HIV Strategic Plan Funding Landscape ($ Millions) Table 4-1 Roles and Responsibility in Coordination and Implementation of National HIV Response Table 6-1 Lesotho HIV NSP 2018 - 2023 Cost Estimates

LIST OF FIGURES

Figure 2-1 HIV Prevalence by Age and Sex (LePHIA 2017) Figure 2-2 Variances in HIV Prevalence and Viral Load Suppression Rates Across Districts Figure 2-3 Number of infections in Lesotho by population group Figure 2-4 HIV Prevalence by key population Figure 2-5 Summary of results against 90-90-90 Targets Figure 2-6 Historical and current trends in HIV Incidence against Fast Track Targets for Lesotho Figure 3-1 Trends in VMMC Uptake in Lesotho (GARPR Report, 2017) Figure 4-1 National Coordination Framework for the Multisectoral Response Figure 6-1 Distribution of NSP Resource Needs: by Programme Area iii

FOREWORD

Nearly five decades into the AIDS response, growing global confidence in countries’ ability to end the epidemic has culminated in a vision set at the United Nations General Assembly Political Declaration on HIV and AIDS in June 2016. This reaffirmed Member States’ commitment to the 2030 Agenda for Sustainable Development, including the resolve to fast track and end the AIDS epidemic by 2030. Lesotho has been identified as a ‘Fast Track Country’ with a severe epidemic by UNAIDS in the 2016 – 2021 strategy. Although, the country is on track to achieve the 90–90–90 targets by 2020, incidence and mortality reduction remain major goals since the country is still one of the world’s most severely affected by the HIV and TB epidemics. This National HIV and AIDS Strategic Plan 2018/19 – 2022/23 has been designed to accelerate and recalibrate the response to the epidemic.

Relying on a rich array of evidence, this National HIV and AIDS Strategic Plan 2018/19 – 2022/23 has been consultatively developed to guide Lesotho towards epidemic control and build an enabling environment that will support eventual elimination. It is aligned to the National Strategic Development Plan and National Health Strategic Plan 2017 – 2022; as well as 2003 Maseru Declaration on the fight against HIV and AIDS in the SADC Region; 2001 Abuja Declaration on HIV and AIDS, Tuberculosis and other related infectious diseases; and Global commitments. This Strategic Plan provides strategic direction over the next five years focusing on high impact interventions, targeting population groups that are vulnerable and at higher risk of HIV infection.

Lesotho is committed to Ending AIDS by 2030. We have shifted from intervention-focus to a people-centred response. We are strengthening focus on human rights and gender equality;

aligning to the 95-95-95 targets; adopting differentiated combination prevention and focusing on innovations. Our success in responding to the HIV and AIDS challenges will depend on our efforts and commitment to intensify targeted actions and resource investments on what we know works to achieve our desired results.

It is my sincere hope that all stakeholders will accord implementation of this strategy the urgency it deserves. An AIDS Free Generation is possible within our times. We have the means and the ability to win this fight.

Dr. Thomas Motsoahae Thabane

The Right Honourable Prime Minister iv

ACKNOWLEDGEMENTS

This National HIV and AIDS Strategic Plan (NHASP) 2018/19 – 2022/23 has been developed through systematic consultative multi-stakeholder dialogues. A series of consultations and reviews by and with people living with HIV, key and vulnerable populations, Ministry of Health and other line ministries, United Nations System, PEPFAR, Global Fund, Civil Society (and private sector) and others delved into programmatic and operational level specificities. Relying on available evidence, stakeholders then made granular, corrective recommendations for strategies and interventions.

The Government of Lesotho wishes to acknowledge with gratitude the valuable support and contribution of the different stakeholders and development partners who made the development of this strategy possible. In particular, the Government of Lesotho wishes to express its special thanks and appreciation to the National AIDS Commission Secretariat for its leadership and coordination of the consultation process, the various technical and thematic working groups that provided technical and policy oversight and advice. The Government further wishes to thank all the organisations and individuals who participated in the consultation and validation workshops during the development of the National HIV and AIDS Strategic Plan. Their dedication and participation ensured the quality, technical soundness and comprehensiveness of the new National HIV and AIDS Strategic Plan.

Special appreciation to the Global Fund to Fight AIDS, Tuberculosis and Malaria through the Ministry of Finance - Project Management Unit for providing the financial support and for technical inputs particularly by the Global Fund Secretariat in Geneva, Switzerland. The Joint United Nations Programme on HIV and AIDS (UNAIDS) – through its Lesotho Country Office, its Regional Office in Johannesburg, South Africa and Head Office in Geneva, Switzerland provided valuable technical assistance for the development of this strategy. The Government further wants to thank the PEPFAR Lesotho Team for their analysis and inputs to the Plan.

The collaboration with the Ministry of Health throughout the process is especially acknowledged. The process was overseen by a multisectoral steering committee with technical guidance from a multisectoral task team.

The Government acknowledges the team of consultants who facilitated in the development of the strategy through the multi-stakeholder consultative processes. The team was led by Mr.

Christopher Alando, who was supported by Dr. Tsitsi Apollo (Treatment), Ms. Helen Jackson (Prevention), Mr. David Masengu (Costing) and Mr. Relebohile Tshehlo (Monitoring and Evaluation).

Finally, I want to express my sincere gratitude to the staff of UNAIDS Lesotho Office, Dr. Alti Zwandor, Ms. Pepukai Chikukwa and Dr. Jamila Jarrakhova; PEPFAR Lesotho, Ms Carol Holtzman; Ministry of Health, Dr. Mosilinyane Letsie and Dr. Llang Maama; National AIDS Commission, Mrs. Keratile Thabana, Mr. Ratlala Montsi, Ms. Lieketseng Masenyetse and Mrs.

Mamonaheng Makhoali for their commitment and tireless efforts in ensuring the success of the project.

Hon. Temeki Phoenix Ts’olo

Minister in the Prime Minister’s Office v

ABBREVIATIONS AND ACRONYMS

ADR Acquired Drug Resistance AGYW Adolescent Girls and Young Women AMR Analytical Measurement Range ART Anti-retroviral Therapy BCC Behaviour Change Communication BeMONC Basic Emergency Obstetric and New-born Care CAGs Community Antiretroviral Groups CBO Community Based Organizations CHAL Christian Health Association of Lesotho CHEAL Comprehensive HIV Epidemic Analysis Study for Lesotho CSO Civil Society Organization CSS Community Systems Strengthening DBS Dry Blood Sample DHIS 2 District Health Information System 2 DRS Drug Resistant-TB Survey DSD Differentiated Service Delivery EID Early Infant Diagnosis EMR Electronic Medical Records EWS Early Warning Systems FBC Full Blood Count FSW Female Sex Workers GHO Global Health Observatory GOL Government of Lesotho HCW Health Care Worker HIVDR HIV Drug Resistance HRH Human Resources for Health HTS HIV Testing Services IMR Incidence Mortality Ratio INH Isoniazid IPC Infection Prevention and Control IPM Incidence Pattern Model IPT Intermittent Preventive Therapy LAM Lipoarabinomannan Assay LDHS Lesotho Demographic Health Survey LePHIA Lesotho Population-based HIV Impact Assessment LOMSHA Lesotho Output Monitoring System for HIV and AIDS LF Lumefantrine LF-LAM Lateral Flow Urine Lipoarabinomannan Assay LMPS Lesotho Mounted Police Service LRF Lab Request Form LTFU Lost to Follow Up M&E Monitoring and Evaluation MDR-TB Multi-Drug Resistant Tuberculosis MOA Ministry of Agriculture and Food Security MOE Ministry of Education and Training MOF Ministry of Finance MOH Ministry of Health MOPS Ministry of Public Service MOSD Ministry of Social Development MoT Modes of Transmission MSM Men Having Sex with Men MTCT Mother to Child Transmission MMG Mother to Mother Support Groups NAC National AIDS Commission NDSO National Drug Service Organization NISSA National Information System for Social Assistance NPT New Prevention Technologies NRL National Reference Laboratories vi

NSP National Strategic Plan NTP National Tuberculosis Programme PCR Polymerase Chain Reaction PDR Pre-treatment Drug Resistance PEPFAR Presidents Emergency Fund for AIDS Relief PHC Primary Health Care PI Protease Inhibitor-based antiretroviral therapy PLHIV People Living with HIV PLWHA People Living with HIV and AIDS PMTCT Prevention of Mother to Child Transmission of HIV PrEP Pre-Exposure Prophylaxis PWID People who Inject Drugs QA Quality Assurance RSSH Resilient and Sustainable Systems for Health SBCC Social and Behaviour Change Communication SCMD Supply Chain Management Directorate SGBV Sexual and Gender Based Violence SRHR Sexual and Reproductive Health Rights SOPs Standard Operating Procedures SRMNCAHN Sexual, Reproductive, Maternal, Neonatal, Child and Adolescent Health and Nutrition TAT Turnaround Times TLD Tenofovir/ lamivudine/ dolutegravir TLE Tenofovir/ lamivudine/ efavirenz TOR Terms of Reference UNAIDS Joint United Nations Program on AIDS UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund VDRL Venereal Disease Research Laboratory test VLS Viral Load Suppression VMMC Voluntary Medical Male Circumcision WDI World Development Indicators WHO World Health Organization vii

EXECUTIVE SUMMARY

The National HIV and AIDS Strategic Plan (NHASP) 2018/2019 – 2022/2023 is set to achieve targets and commitments in the Political Declaration on HIV and AIDS “On the Fast Track to

Accelerating the Fight against HIV and to Ending the AIDS Epidemic by 2030”, that Lesotho, together with other member states adopted in the June 2016 High Level Meeting. This declaration set ambitious targets aimed at Ending the AIDS Epidemic by 2030 and was further complimented by several other global and regional commitments including the HIV Prevention

2020 Road Map “Accelerating HIV prevention to reduce new infections by 75%”, for which the country has also adopted.

These commitments are critical to Lesotho as it is still heavily affected by the epidemic, with high prevalence at 25.6% (30.4% in females and 20.8% in males) and incidence of 1.47%

(1.74% in females and 1.22% in males) in adults aged 15 – 59 years in 2017. Estimates show that adults 15 years and above living with HIV are 306,000 and children aged 0 to 14 years are approximately 13,000. Evidence indicates that annual HIV incidence declined marginally, placing Lesotho at the top of countries with high incidence globally. The HIV epidemic in

Lesotho is generalized and hyperendemic, with HIV prevalence highest in female sex workers, men having sex with men, factory workers and prison populations. Though the main mode of transmission is heterosexual contact, the underlying causes are entrenched in socio-cultural and economic dimensions. HIV is the main driver of Lesotho’s twin epidemic with tuberculosis;

where TB is a leading cause of mortality among people living with HIV.

The introduction of Antiretroviral Therapy in the early 2000’s and the adoption of Test and treat in 2016 has had a direct effect on AIDS related deaths, from a peak of 12,000 deaths in 2005 to the current 5,000 deaths in 2017. Population-level viral load suppression (VLS) rates were estimated at 67.6%. In the last National HIV & AIDS Strategic Plan (2013 – 2018) Lesotho adopted the 90–90–90 targets, where according to the LePHIA (2017) the country is now at

77-90-88 amongst people living with HIV aged 15 to 59 years; with 77.2% (81.5% females and

71.0% males) reporting knowing their HIV status; 90.2% (90.6% females and 89.4% males) who know their HIV status reporting current use of ART; and 88.2% (88.3% females and

88.4% males) of those reporting current use of ART virally suppressed. However, the scope of the response has not always been adequate to address the diverse sources and drivers of the epidemic, with limited comprehensive combination prevention packages that can make a significant and recognizable dent on new HIV infections.

This National HIV and AIDS Strategic Plan (NHASP) 2018/19 – 2022/23 has been designed to accelerate and recalibrate the HIV response. The plan was developed through multi-stakeholder consultative processes; with a multisectoral steering committee, task teams and technical working groups consisting of government, development partners, civil society including Networks of People Living with HIV, representatives of key populations, private sector groups - prior to district, national and international peer reviews, and national validation.

The plan was also informed by a rich array of evidence.

The Vision of the National HIV and AIDS Strategic Plan (NHASP) 2018/19 – 2022/23 is

“Ending AIDS by 2030”, with three strategic goals:

Reduced new HIV infections from 13,300 in 2017, by at least 50% by 2023.

Reduced AIDS related deaths by 50% by 2023, from 4,900 in 2017.

Mother to child transmission of HIV eliminated, from 11.3% to less than 5% by 2023.

The above will be met through achievement of the following program results:

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1. 95% of people aged 15 and over at risk for HIV have accessed combination HIV prevention

2. Mother to Child Transmission Eliminated and 95% of children living with HIV on treatment

3. Test and Treat Cascade Fast Tracked to attain 95-95-95 targets

4. Gender and Human Rights related barriers to service delivery, accessibility and utilization removed

5. Strengthen national social and child protection systems to ensure 75% of PLHIV, at risk of and affected benefit from HIV-sensitive social protection

6. At least 40% of the HIV/TB response is community-led and sustainable

7. Health System is people-centred, and sustainably integrates HIV, TB, Hepatitis and other infection

8. Increased efficiencies and financial investments in HIV and TB programs to 90% of the NSP budget

In this strategic plan, emphasis will be on a people-centred response with differentiated service delivery for HIV testing and antiretroviral therapy, aligning to the 95-95-95 targets. The country commits to addressing gender and human rights barriers to access and uptake of services with tailored and differentiated combination HIV prevention. Several innovations have been adopted for national scale -up for example HIV self-testing; index HIV testing; Pre-exposure prophylaxis; male corners with comprehensive health services for men; new and shorter course ARV regimen; technologies to reduce viral load and early infant diagnosis turnaround times; unique identifier electronic medical records for patient tracking.

The cornerstone to successful implementation of the National HIV and AIDS Strategic Plan lies in effective and efficient coordination of the national response. The National AIDS Commission re-established under the Office of the Prime Minister in 2015/2016, is mandated to coordinate the national response to HIV through implementation of this Strategic Plan. It executes this mandate in partnership with other stakeholders through a multisectoral and decentralized framework. These include; the Ministry of Health, Ministry of Local Government and Chieftainship Affairs and other non-state partners. The framework defines the roles of each stakeholder, sector and coordinating entity at national, district and health centre /community levels, premised on the Three Ones principles. Thus, coordination of the response nationally should be strengthened to inform and ensure that HIV and AIDS is mainstreamed and integrated into sectoral plans, programs and budgets.

During the five years between 2018 and 2023, Lesotho will require US$1.1billion for the entire National HIV Response, gradually increasing from US$188million to US$236 million in the fiscal years of 2018/19 and 2022/23 respectively. A major proportion of the funding is either committed, pledged or within Lesotho’s fiscal space or annual consolidated budgets. Though the county will still require external financial support during the five years of implementation of the strategy, a significant proportion of the funding especially for treatment, social protection, health systems will be from domestic sources.

1. CONTEXT AND RATIONALE FOR A NEW STRATEGIC PLAN

1.1 Introduction and Rationale

Nearly five decades into the AIDS response, growing global confidence in countries’ ability to end the epidemic has culminated in a vision set at the United Nations General Assembly Political Declaration on HIV and AIDS in June 2016, which reaffirmed Member States’ commitment to the 2030 Agenda for Sustainable Development, including the resolve to fast track and end the AIDS epidemic by 2030 and implement the Agenda on Financing for Development.1 In aligning its 2016-2021 Strategy to the new global vision, UNAIDS identified Lesotho as a ‘Fast Track Country’ with a severe epidemic. The Lesotho Population-Based HIV Impact Assessment (LePHIA, 2017), a nationwide cross-sectional household survey, estimated HIV prevalence among adults aged 15 to 59 years at 25.6% (30.4% females and 20.8% males); and as high as 49.9% among women aged 35-39. More than 330,000 people live with HIV. Incidence remains high at 1.47% in adults 15 to 59 years, 1.74% in females and 1.22% in males, with more than 13000 new adult infections annually. Population-level viral load suppression (VLS) rates were at 67.6%. Estimated at 2.1%, paediatric HIV prevalence is among the highest in the world. Surveys of key and vulnerable populations estimated prevalence at 71.9% among female sex workers, 43.3% among Factory Workers, 32.9% for MSM and 31% among prisoners.

The previous National HIV and AIDS Strategic Plan 2011-2016 was extended to 2018 to align with the National Strategic Development Plan and respond to the UN Political Declaration on HIV and AIDS of 2016. It outlined interventions for HIV prevention; treatment care and support; impact mitigation; response coordination and management towards halving new infections and AIDS and TB-related deaths by 2018; eliminating mother to child transmission and improving efficiency and effectiveness of national response planning, coordination and service delivery. The strategy also sought to fast track the response in alignment to global commitments and 90-90-902 targets and was synchronized with the national Tuberculosis strategy. The 2017 LePHIA findings imply that the country is on track to achieve 90–90–90 targets by about 2020. Nonetheless, incidence and mortality reduction remain major goals since the country is still one of the world’s most severely affected by the HIV and TB epidemics.

This new strategic plan has been designed to accelerate and recalibrate the response to the epidemic.

1.2 How this Plan was Developed

Relying on a rich array of evidence, this National HIV and AIDS Strategic Plan 2018/19 – 2022/23 has been consultatively developed to guide Lesotho towards epidemic control and build an enabling environment that will support eventual elimination. The plan is informed by the National Strategic Development Plan and Health Sector Strategic Plan, as well as global guidelines, Africa Union and SADC commitments. Several analytical studies investigated the epidemic and reasons for slower reduction in incidence, gaps, constraints and barriers to implementation progress, and challenges.

Key among these were:

• The Lesotho Population-Based HIV Impact Assessment (LePHIA), performed between 2016 and 2017, which estimated HIV prevalence, incidence and viral load suppression;

• A 2017 prevention assessment and gap analysis which provided insights into programmatic limitations and proffered remedies for the country’s prevention response;

• The Comprehensive HIV Epidemic Analysis for Lesotho (CHEAL), which assessed HIV trends and underlying sub-population level causalities, building on the Incidence Pattern Model;

• An external Joint TB/HIV (and Viral Hepatitis) Program Review analysed progress, challenges and made recommendations to strengthen each intervention;

1 UNGA Seventieth Session Agenda item 11: Implementation of the Declaration of Commitment on HIV/AIDS and the political declarations on HIV/AIDS; Addis Ababa Action Agenda of the Third International Conference on Financing for Development.1

2 Where 90% of people living with HIV know their status, 90% of people who know their status are accessing treatment and 90% of people on treatment are virally suppressed

• The Spectrum suite of tools, which uses HIV prevalence and incidence from population surveys including LDHS and LePHIA to model the HIV epidemic, provide estimates and project key indicators such as number of new infections, number of people living with HIV, mother-to-child transmission rate, mortality and others;

• Customized transmission-probability models to prioritize target populations and interventions (programmatic scope) and determine the optimal program coverage (scale) required to achieve the desired impact on the epidemic;

A systematic consultative multi-stakeholder dialogue guided development of the new strategy. A series of consultations and reviews by people living with HIV and / or TB, National AIDS Commission, Ministry of Health and other line ministries, United Nations System, PEPFAR, Global Fund, broad Civil Society (and private sector) and others delved into programmatic and operational level specificities, relying on available evidence to make more granular, corrective recommendations for strategies, interventions and activities. An analysis of all the above evidence by implementers and policymakers determined common reasons for lower coverage and impact.

National AIDS Commission coordinated the development of this plan through a multisectoral steering committee, task teams and technical working groups consisting of government, development partners, civil society including networks of People Living with HIV, representatives of Key Populations and private sector groups, and technical assistance; prior to international peer reviews, district and national level reviews and validation.

What is New in This Plan o Adoption of results-based planning language and accountability framework (Strategic Results, or Goals;

Program Results; Result Areas, and Outcome Results cascading into output level results at the operational planning level) o A shift from intervention-focus to a people-centred response. Examples include differentiated service delivery (DSD) for ART such as Community ART Groups (CAGs) and ART Refills Groups o Strengthened focus on gender o Alignment to the 95-95-95 Targets o Differentiated Combination Prevention o Innovations in interventions, products, activities and delivery models: differentiated HTS; self-testing;

PrEP; male corners providing comprehensive health services for men; unique identifier EMR/ options for blockchain technologies for patient identification and tracking; Index testing; dually qualified VMMC nurse initiates (professional and cultural qualifications to expand VMMC service delivery and acceptability); TLD and TLE combinations; shorter coursed regimen; LF-LAM for severely immunocompromised;

technologies to reduce viral load and EID TATs; accelerate essential drug distribution in hard-to-reach areas, among others.

o Revamped and costed Multisectoral Coordination Framework; new HIV and TB coordination structure;

and a collaborative implementation framework o Standardization of DHIS 2: Integration of LOMSHA; EMR; Key Populations and partner reporting;

extension of computerization of DHIS 2 to primary level;

o Review of service delivery models and response/ allocation prioritization criteria (From geography to sources and drivers of the epidemic); and o Advancing the Global Fast Track Vision from control to elimination.

1.3 Operational and Socioeconomic Context

The Kingdom of Lesotho’s 2,007,201 population (Bureau of Statistics, 2016) lives within a high-altitude network of rivers, valleys descending to 1400m above sea level and mountains peaking at 3,482m. The country’s 30,355 km² is completely encircled by the Republic of South Africa. The western half of the country, encompassing the capital Maseru, Mafeteng, Leribe, Teyateyaneng and other towns, is more densely populated. An estimated 57.8 % of the population lives below the poverty line (World Bank, 2016). Maternal, infant and child mortality have been on a downward trend since the 1960s but remain relatively high.

Economic Context: Lesotho is a lower middle-income economy with GDP per capita of USD 1020. The economy is based on agriculture, livestock, manufacturing and mining industries, with workers’ remittances from South Africa another major source of inflows. Services comprise 60% of the country’s GDP, while industry (mining, manufacturing, construction, energy production ) comprise 34.6% and agriculture 5.3% (World Bank 2017 estimates). Most formal employees are women working in the garments sector, while men are mostly migrant labourers in South African mines, working under inadequate health conditions and away from their families for up to three quarters of the year. The Government of Lesotho (GoL) is another significant employer. Still, unemployment remains high, at 28%, coupled with high inequality and poverty. Youth and some elderly populations are net dependents, while the Gini-coefficient shows a sizable gap between the rich and poor. The economic growth rate between 2011 and 2015 averaged 4.5% but slowed to 2.3% by 2017. Economic growth prospects will be boosted by expected increases in mining and construction activity during this plan period (World Bank, 2017), increasing internal migration which is among the HIV epidemic drivers.

Table 1-1 Summary of Critical Demographic, Health and Economic Indicators

PARAMETER VALUE YEAR (DATA SOURCE)

Population 2,007,201 BoS (2016)

Urban Population 31.7% BoS (2016)

Popn. In extreme poverty 57.8% World Bank, 2017

GDP Per Capita (PPP $) $1020 World Bank, 2017

Life Expectancy at Birth 53.6 Years (F 56; M 51.6) WDI (2015)

Maternal Mortality 1024/ 100000 live births LDHS (2014)

Under-5 Mortality 80.4 /1000 live births WDI (2016)

Stunting Prevalence 33% UNICEF/ LDHS (2014)

Vaccination coverage 68 % BoS (2016)

Number of Orphans 210 712 (27% of Children) BoS (2016)

Health Budget as % Total 15% MOF, 2017

Health Expenditure % GDP 10.6% World Bank (2015)

Public Health Expenditure 76% World Bank (2015)

Out of Pocket Expenditure 16.5 % World Bank (2015)

Physicians Density Below 0.1 per 1000 population WHO, WDI

Nurses Density 0.6 per 1000 population WHO, WDI

Adult Literacy Rate 85% (94.5% for female) WHO, WDI

Demographic Context: The 2016 household census enumerated the total population of Lesotho as 2,007,201 distributed as follows. 38% of the population is youthful (that is, falling between the age ranges 15-34 years), at a time when youth unemployment, another driver of the epidemic, remains high. At least 42% of the population is aged 0-19. On average, 51% of the population is female. Population varies across the 10 administrative districts of Maseru (the Capital City); Leribe, Berea, Mafeteng, Mohale’s Hoek, Thaba-Tseka, Botha-Bothe, Quthing, Mokhotlong and Qacha’s Nek. The highest population was in Maseru with 519,186 people, while the lowest in Qacha’s Nek (74,566) people. Household shocks, including death, job loss, or crop failure are the main “push” factors contributing to general, and especially female migration in Lesotho, with 43% of families reporting at least one member living away from home (Botea et al. 2017). Children (0-17 years) comprise 38.1% of the total population (BOS, 2016)- 38.1%. About 18% of those aged 3-17 are not in school (10.1% are males and 7.9% are females). Only about half (54%) of Lesotho’s children live with their parents. Up to 48% of orphans live with their grand-parents, while 12% live in child headed households. 24 % of girls get married before they attain 18 years of age while the likelihood of getting pregnant for orphan girls is twice as high as that of girls with both parents. 33% of children were stunted, while 3% were wasted by 2014 (LDHS). Of the more than 200,000 orphans, significantly more are paternal rather than maternal or double orphans.

1.4 Health Systems

Health Infrastructure: By the end of 2017, there were at least 236 health facilities in the country, including one referral hospital, two specialized hospitals, 18 general hospitals, four primary hospitals, four filter clinics and 207 health centres (MOH, 2017), Forty percent (40%) of the health centres and 58% of hospitals are MOH-owned.

Thirty Eight percent (38%) of health centres and the same proportion (38%) of hospitals are owned by Civil Society.

Health centres are the first point of care for HIV and other diseases. Nine out of 10 private for-profit health facilities are situated in urban areas within western districts of Maseru, Berea, Mafeteng, and Leribe. Some non-governmental organizations (NGOs) complement service delivery to a significant proportion of the population.

About 80% of the population accesses improved water sources, while only 30% has improved sanitation - critical indicators in mother and child health (WHO, 2015). The proportion of facilities providing basic emergency services are limited (UNICEF, 2015).

Human Resources: Overall, Lesotho’s health system suffers an acute shortage of human resources. There are only six nurses, one physician and a pharmacist for every 10000 people. One doctor and three nurses serve about 1000 people living with HIV or TB. The Annual Joint Review report of FY 2015/16 found that about 50 percent of the health centres run by the government and civil society were staffed according to minimum staffing requirements. The overall vacancy rate was 22% in 2015/16, a significant improvement from 43% reported the previous year. Nearly 5000 community/ village health workers, traditional birth attendants, distribution agents and water minders complement service delivery at community level, critical in ensuring reduction in some disease burden including polio, waterborne diseases and delivery of HIV interventions within the prevention, test and treat continuum. Still, the ratio of community or household level health workers to PLHIV and TB clients is still below the WHO recommended threshold and this is evident in high rates of Loss to Follow Up. The Health Sector Strategy prioritizes community level service delivery as central to health service promotion; hence strengthening it to efficiently support the achievement of 95-95-95 targets will be a critical Program Result.

Procurement and Supply Chain Management (Medicines, health commodities, medical devices and medical technologies): The procurement and supply chain in Lesotho is coordinated by Supply Chain Management Directorate (SCMD) of MOH, with development partners playing critical supportive roles in financing, while some assist with procurement and quality assurance. SCMD also participates in selection of products by MOH programs. The system can ensure health commodity security. Storage warehousing and distribution through to community level is coordinated mainly through NDSO, an agency of MOH. The system for stock monitoring and reporting at facility level has improved due to the rollout of informed push reporting and requesting tool. Forecasting has been improved, but challenges remain in budgeting when some programs fail to use forecasted results to inform their budgets. Disbursement of funds from MOF is done on a quarterly basis and this affects procurement and supply of health commodities. Current regulations do not allow pre-financing/ prepayment of orders as required by suppliers, occasioning long lead times, with a limited pool of local suppliers at country level. Gazettement of SCMD has been delayed hence budget size and staffing is limited while the sustainability of activities is at risk.

This is a critical risk in the context of the global fast track targets envisioned in this strategy, and in the United Nations declaration.

Pharmaceutical Services: Lack of a fully functional national drug regulatory agency has led to gaps in registration and product quality monitoring within the country. ARVs procurements in Lesotho are made from WHO prequalified suppliers, while that of TB commodities is done under the Global Drug Facility (GDF) mechanism. Patient data reported from health facilities has been of poor quality, characterized by under-reporting, inaccuracies and limited disaggregation of data.

Strategic Information: MOH and partners have made major advances in deploying systems and tools to generate and manage strategic information. The country introduced a revamped version of the electronic District Health Information System (DHIS2); deployed and trained human resources in M&E. Obtaining reliable and high-quality data for decision-making is still a challenge owing to marked discrepancies between routine and survey data, inadequate human resource (as evidenced by a 65% M&E human resource gap) and nascent unique patient identification and tracking systems. EPI, HIV and TB data systems are yet to be merged while segmented deployment by the Global Fund and better funded PEPFAR implementers have led to an unbalanced HMIS system.

Communication between the HMIS unit and programs has been poor over the years; with limited sharing of information. DHIS 2, the community information system (LOMSHA), financial and human resources information systems are yet to be merged as recommended globally; while key population; unique patient identification, and social assistance information data is not integrated in DHIS 2 leading to potential duplication and some inefficiencies in program design and implementation.

1.5 Human Rights, Law and Gender Context

Harmful laws, policies and practices; inadequate legal literacy and limited access to legal services continue to affect the implementation environment and achievement of results. A Report on the Assessment of the legal environment for HIV and AIDS in Lesotho (2016) underscores lack of awareness of laws among people living with or affected by HIV in Lesotho. Several HIV related laws need review, simplification or wider dissemination. The Sexual Offences Act (2003) and Legal Capacity of Married Persons Act (2006), Gender and Development Policy;

National HIV and AIDS Policy (2006 and the AIDS Bill are not yet updated to fully meet the rights and needs of PLHIV and vulnerable groups. The Children's Protection and Welfare Act 2011 and the Legal Capacity of Married Persons Act 2006 do not provide for child marriage as a punishable offence. Laws requiring updates to better mitigate against the effects of HIV include the Elderly Act, Children’s Welfare Act, the Labour law and the Disability Equity Bill.

Gender inequality, gender-based violence and many forms of human rights violations significantly influence the twin HIV and TB epidemics in Lesotho3. These include sexual and gender-based violence, harmful cultural norms and practices related to gender such as early marriage, persisting stigma, discrimination, inadequate access to health services, and unsafe working conditions. According to LePHIA (2017), 10% of women and girls have been forced to have sex, while the Gender Links Report (2014), states that 62% of Basotho women have experienced intimate partner violence over their lifetime, and 86% had experienced gender-based violence. More than a third of men (37%) reported perpetrating, intimate partner violence, with. 16% of men admitting to having committed rape. Stigma and discriminatory attitudes deter uptake of health services: The Lesotho Stigma index (2013) reported stigma and discriminatory practices in social service facilities, including stigma by duty bearers within and outside the healthcare setting.4 Many groups face exploitative and poor working conditions including miners in neighbouring South Africa who suffer high rates of TB/HIV incidence; Women, children and adolescents who engage in sex work or exploitative relationships and some factory workers, especially women in the garment industry who continue to earn low wages, and remain classified among the working poor.

3 LepHIA (2017); Legal Environment Assessment (2016) 4 The People Living with HIV Stigma Index (2013); UNAIDS, GNP+, ICW Global.

2. EPIDEMIOLOGICAL TRENDS AND RESPONSE ANALYSIS

The HIV epidemic in Lesotho is generalized and hyperendemic, with HIV prevalence highest in female sex workers, men having sex with men, factory workers and prison populations. Though the main mode of transmission is heterosexual contact, the root causes driving the epidemic are socio-cultural and economic in nature. HIV is the main driver of Lesotho’s twin epidemic of Tuberculosis, while TB is a leading cause of comorbidity and deaths among people living with HIV. The country ranks high in TB-HIV comorbidity with a co-infection rate of 72%, the world’s second highest HIV prevalence and fourth highest severity of TB burden (incidence per capita).

2.1 Epidemiological Trends

Trends in incidence: The Lesotho Population Based HIV Impact Assessment (LePHIA 2017) estimated annual incidence among people aged 15 to 59 at 1.47 in 2016. Incidence is higher in females (1.74%), than in males (1.22%.) This corresponds to at least 13,000 new adult HIV infections annually. Between the ages 15-49, incidence is 1.55 (1.81 female and 1.33 male). Adult HIV Incidence peaked at 2.27% per 100 person-years (PY) in 1997, steadily decreasing to 1.55 [0.98, 2.11] new infections 2017 (CHEAL 2017). During the last ten years however, the HIV epidemic has stabilized. Comparative analysis using the 15-49 age group shows that the number of new infections has declined from an estimated 18,870 new infections in 2007 to 14,706 in 2017 (Spectrum Estimates, 2018), representing a drop of only 22% during the last decade.

Understanding where and why new infections are occurring is the most important factor for appropriately targeting HIV prevention responses. In 2017 an analysis was undertaken using the Incidence Patterns Model (Avenir Health, 2018) and working with DHS 2014 data. The model estimated that the great majority of new infections occur in the general population, with over 68% of all new infections occurring in never married females, never married uncircumcised males, and sero-discordant couples with the male as the HIV positive partner. Only a small percentage (7%) of new infections were estimated to occur in female sex workers and men having sex with men because of the relatively small size of these populations, although their HIV prevalence is higher than that in the general population.

HIV Prevalence: Prevalence of HIV among adults ages 15 to 59 years in Lesotho is 25.6%: 30.4% among females and 20.8% among males (LePHIA, 2017). This corresponds to approximately 306,000 people living with HIV (PLHIV) aged 15 to 59 years. Prevalence among children ages 0 to 14 years is 2.1%: 2.6% among females and 1.5% among males. This corresponds to approximately 13,000 children living with HIV (CLHIV) aged 0-14 years (LePHIA, 2017). The highest HIV prevalence in all ages and both sexes is 49.9% in females aged 35 to 39 compared to 46.9% in males aged 40-44 years. Variances in prevalence between males and females are most marked between 20 to 24-year-olds, over four times as high in females (16.7%) than in males (4.0%). All 10 districts of Lesotho have high HIV prevalence, ranging from 17.8% to 29.3% adult prevalence, with five lower lying districts with higher population density and stronger economic activities accounting for an estimated 75% of all people living with HIV (PLHIV).

Figure 2-1 HIV Prevalence by Age and Sex (LePHIA 2017)

Heterogeneity of the epidemic: The HIV epidemic is hyperendemic with geographical and population-based variations (gender, age, social and individual behavioural differences). Spatial and temporal variances in prevalence and incidence have been witnessed in the whole country. By geographical area, prevalence varies by district from a low of 17.8% in Butha Buthe to a high of 29.3% in Mohale’s Hoek. Viral load suppression rates are highest in Berea at 71.7% and lowest in Mokhotlong at 58.8%.

Figure 2-2 Variances in HIV Prevalence and Viral Load Suppression Rates Across Districts

Trends over time: Trends in the HIV epidemic over time show that it has persisted at high prevalence across all districts. In 2004, HIV prevalence in excess of 20% in Leribe (29.7%), Maseru (25.5%) and Berea (24%) and others were possibly associated with increased population of women working in garment factories in these districts.

In 2017 the highest prevalence districts became Mohale’s Hoek (29.3%), Berea (29.3%) and Maseru (27.8%). The prevalence across districts and in different years have overlapping confidence intervals- hence may not imply any major differences. The studies however confirm urbanization and labour migration as significant drivers of the HIV epidemic, though also emphasizing the need for a comprehensive HIV response across the whole country.

Heterogeneity of the epidemic is also observed along socioeconomic and geographic strata. A review of HIV prevalence across urban and rural areas, while checking for employment types found that HIV prevalence is consistently higher in urban areas and among the employed. For employed adults, prevalence is higher among the unskilled, self-employed or those in low-skilled jobs than among the professional, technical or managerial cadres (CHEAL, 2017). Men with no education are increasingly more likely to be HIV-positive than their counterparts with some level of secondary or tertiary education. On the other hand, women with some primary level education are more likely to be infected with HIV than their counterparts with no education, secondary or tertiary level education. (LDHS, 2004, 2009 and 2014.)

Viral load suppression (VLS) rates: Among HIV-positive adults ages 15 to 59 years viral load suppression (VLS) rates have risen from less than 45% in 2011 to 67.6%: 70.5% among females and 63.4% among males. Prevalence of VLS among people living with HIV is highest among older people ages 45 to 59 years: 80.3% among HIV-positive females and 81.4% among HIV-positive males. In contrast, prevalence of VLS is distinctly lower among younger adults: 50.9% among HIV-positive females ages 15 to 24 years and 46.1% among HIV-positive males ages 25 to 34 years. (LePHIA, 2017)

Morbidity and mortality: Scale up of ART and increasing VLS has halved AIDS related mortality from 10,345 in 2007 to 4,908 in 2017 (HIV Estimates and Projections 2018). Key drivers of HIV morbidity are Tuberculosis, Viral Hepatitis, pulmonary and a range of neonatal and child infections related to lack of access to clean water, sanitation and hygiene, among others (WHO/ World Bank Global Health Observatory) More men than women die of HIV-related causes, primarily due to poor health-seeking behaviour, translating to lower HTS uptake or access; and lower ART enrolment and retention in care.

2.2 Sources of New Infections and Drivers of the Epidemic

2.2.1 Sources of New Infections by Population Characteristics

A comprehensive analysis of the distribution of new infections according to easily identifiable characteristics, through the Incidence Patterns Model, validated by previously known information from the Lesotho Demographic Health Surveys of 2014; BSS 2012 and compared to LePHIA 2017, show that most new infections in 2017 were among women compared to men, and outside of stable relationships. However, uncircumcised men never married females and sero-discordant couples (where male partner was HIV positive) constituted a sizable proportion of new infections. The graph below reflects the Incidence Patterns Model estimates (CHEAL, 2017) In this model, the number of new infections in a population group depends on the group’s size and its disease incidence. The largest number of new infections was estimated to occur among women who had never married - mostly young women before marriage (3,823; 29.4%); uncircumcised men who had never married (3,374; 25.9%), and sero-discordant couples with the male partner HIV+ (1,760, 13.5%) – all of whom contributed 69% of new infections.