National_HIV_Prevention_Strategy_(Multisectoral).pdf

GOVERNMENT OF LESOTHO

NATIONAL HIV PREVENTION STRATEGY

FOR A

MULTI-SECTORAL RESPONSE

TO THE

HIV EPIDEMIC IN LESOTHO (2011/12-2015/16)

NATIONAL AIDS COMMISSION

Powered to conquer HIV and AIDS

Preface

Since the inception of the National HIV and AIDS Strategic Plan, 2006 – 2011, Lesotho’s national HIV prevention response has resulted in significant progress towards the goal of reducing the number of new HIV infections. Continuing this progress, Lesotho has developed this National Multi-Sectoral HIV Prevention Strategy, 2011 – 2015. Key elements from this strategy will inform the forthcoming generation of the National HIV and AIDS Strategic Plan.

The National Multi-Sectoral HIV Prevention Strategy, 2011 -2015 sets out the overarching goals for the response to HIV prevention and reaffirms Lesotho’s commitment to a comprehensive response. A wide range of analyses and consultations carried out at the national, district, and community levels throughout Lesotho have helped to ensure that the strategy is based on the most up to date understanding of the epidemic, that the activities are based on evidence of what works in Lesotho and elsewhere, and that the strengths and weaknesses of the systems and mechanisms for responding to HIV prevention are addressed.

The development of this National Multi-Sectoral HIV Prevention Strategy, which was carried out between July and December 2010, has been based on broad participation of all of the stakeholders involved in HIV prevention in Lesotho: communities, civil society organisations (CSOs), non-governmental organisations (NGOs), government, and development partners. In addition, the strategy incorporates recommendations and direction from a number of existing national and sectoral policies, guidelines, evaluations, and research. As a result, we are confident that the strategies identified in the plan are those that reflect the key drivers and factors of Lesotho’s HIV epidemic.

The National Multi-Sectoral HIV Prevention Strategy, 2011 - 2015 presents all stakeholders in Lesotho’s HIV prevention response with major challenges. Basotho should commit to scaling-up the implementation of HIV prevention with the aim of becoming more effective, efficient, and coherent in our common efforts to reduce the number of new infections. This document provides clear direction coupled with evidence-based strategies for achieving the ambitious results to prevent the further spread of the epidemic.

It is now our responsibility to rise to the challenge and combine the necessary individual and collective resources in our drive towards reducing the number of new HIV infections. Let us get to work, or rather continue our work, with renewed energy and determination in the fight against HIV and AIDS.

The Right Honourable The Prime Minister

Dr. Pakalitha Mosisili

Acknowledgements

The Government of Lesotho (GOL) through the National AIDS Commission (NAC) wishes to acknowledge with gratitude the valuable contribution of a large number of stakeholders who made it possible to develop the National Multi-Sectoral HIV Prevention Strategy in a collaborative manner.

We wish to thank the public sector and in particular the Ministry of Health and Social Welfare (MOHSW), the Ministry of Local Government and Chieftainship (MOLGC), and the Ministry of Gender, Youth, Sport and Recreation (MGYSR), the Ministry of Education and Training (MOET), the Ministry of Labour and Employment (MOLE), the Ministry of Public Service (MOPS) and other ministries.

We would also like to thank the organisations that have a particular perspective on HIV prevention from the community level, which include non-governmental organisations (NGOs), civil society organisations (CSOs), faith based organisations (FBOs), people living with HIV (PLHIV), traditional leaders, District AIDS Committees (DACs), and Community Council AIDS Committees (CCACs) and the communities. They participated in consultations and review meetings, and provided valuable written and verbal feedback on the HIV prevention response in Lesotho, challenges and achievements, recommendations and objectives, and key strategies and activities. As such, not only was the quality of the final product greatly enhanced, but also the process was inclusive, and the final strategy represents the key priorities of multiple stakeholders.

We are also grateful for the financial and technical support from our development partners.

Specifically, we wish to express special thanks and appreciation to the members of the Prevention Thematic Team, the Core Team, and the High-Level Forum for their invaluable contributions in providing policy and strategic guidance.

Furthermore, we would like to express special thanks to the United States Agency for International Development (USAID), the Joint United Nations Programme on HIV and AIDS (UNAIDS), the Technical Support Facility (TSF) for Southern Africa, and Population Services International (PSI) for their support in providing technical and financial assistance for the consultants who contributed to the development of this national strategy.

We thank the consultants Mr. Thomas Scalway, Ms. Chrissy Carmody, and Ms. Mary Wieczynski Furnivall, who assisted in developing the strategy. This document would not have been possible without the support from NAC staff, both at the district and central levels.

Dr. ‘Molotsi Monyamane

Acting NAC Board Chairperson

Executive Summary

Lesotho is currently experiencing one of the most serious HIV epidemics in the world, although there is evidence that the epidemic has somewhat stabilised in the past few years. The HIV prevalence rate in 2009 among Basotho aged 15-49 was 23% and in 2007, annual adult HIV incidence was 1.7% or approximately 21,000 new cases that year. Projections on ART needs in 2009 were such that 117, 903 people would need treatment. In the same year the survival rate of both adults and children with HIV known to be on treatment 12 months after initiation was 80% which was an increase from 74.4% in 2007. AIDS mortality on the other hand stood at 11,000 in 2009.

The National Multi-Sectoral HIV Prevention Strategy, 2011 – 2015, describes how the national HIV prevention response will reduce levels of HIV incidence by directly addressing the drivers of Lesotho’s epidemic. The 2009 Lesotho Demographic and Health Survey (LDHS) data indicate a rapid rise in HIV prevalence among young people, particularly young women. The total number of HIV-infected females aged 15-49 is 27%, but significantly lower at 18% for men the same age. By age 20-24, approximately 24% of women are infected; prevalence increases to 35% for the age cohort 25-29 and peaks at 42% for women throughout their thirties. Male prevalence lags behind female prevalence by about five years, but similarly reaches about 40% among men aged 30-45. With such high average levels of prevalence nationally, the pool of at-risk individuals is likely at or near saturation among adult men and women aged 25-44.

For the most part, HIV prevalence levels have remained the same since the first population-based HIV testing was conducted five years ago as a component within the 2004 LDHS.

Although this might be in part attributed to the growing number of HIV-infected Basotho who receive care and support services, including antiretroviral therapy (ART), HIV prevalence levels are essentially unchanged between the two surveys among young adults aged 15-24. In the absence of HIV incidence testing, examining HIV prevalence within this age group is an internationally accepted proxy for monitoring new HIV infections. As such, the complexity of the epidemic and the underlying factors require a reinvigorated multi-level approach to curtail the number of new infections.

This five-year National Multi-Sectoral HIV Prevention Strategy sets forth ambitious results aimed at reducing HIV incidence by 50% by 2015. It is closely aligned to Lesotho’s revised National HIV and AIDS Strategic Plan, 2006 – 2011, the Health Sector Policy on Comprehensive HIV Prevention, and the Essential HIV and AIDS Service Package (ESP). The strategy is supported by a strategic framework and a five-year monitoring and evaluation (M&E) plan that draws upon the most current data within the country. These tools will serve to guide and coordinate the efforts of those working at national, district and community levels. The accompanying three-year costed Operational Plan will assist stakeholders with resource allocation and programme implementation.

A number of overarching principles underpin the strategy: addressing the key epidemic drivers;

creating an integrated, comprehensive response; strengthening a decentralised response;

improving the use of strategic information; employing a human rights-based approach; and intensifying social and behaviour change communications (SBCC). Following current best practices, the National Multi-Sectoral HIV Prevention Strategy, adopts a combination prevention approach that systematically identifies and targets the behavioural, biomedical and structural drivers of the epidemic. The approach is arranged within a results-based framework that will assist with the monitoring of progress and results.

The strategy’s four objectives are:

• to reduce the sexual transmission of HIV;

• to reduce mother to child transmission of HIV;

• to prevent blood-borne transmission of HIV; and

• to strengthen the systems necessary for an effective national HIV prevention response.

Within these four objectives, the National Multi-Sectoral HIV Prevention Strategy calls for a reinvigorated response to HIV prevention. First and foremost is the need to focus on the main drivers of Lesotho’s epidemic: multiple and concurrent sexual partnerships. The strategy underscores the need to address the complexities of the motivations, behaviours, and social norms that shape these deeply rooted practices. Other priorities and key objectives build upon the significant achievements made to date in policy, research, and programme implementation.

This includes building upon and expanding results in HIV testing and counselling (HTC), SBCC to address behavioural, biomedical, and structural epidemic drivers, the prevention of mother-to-child transmission (PMTCT), the prevention and management of sexually transmitted infections (STIs), condom promotion and distribution, infection control and waste management, and blood safety.

The strategy emphasises the scaling up of emerging HIV prevention initiatives within the country. These include, among others, Positive Prevention services for HIV-infected individuals, the roll out of male circumcision (MC) with a focus on engaging traditional circumcisers, and the implementation of the neonatal and the existing voluntary adult male circumcision and SBCC for HIV prevention among vulnerable groups, especially migrant populations, and the youth. The strategy reinforces the need for all HIV prevention programmes to address underlying factors that create risk and vulnerability to HIV infection. These include risky traditional, cultural, and gender norms and practices, lack of male involvement in reproductive health care, and stigma and discrimination toward those infected with HIV.

The strategy also highlights the need for innovation to address dynamics and factors that contribute to HIV incidence or affect specific populations. These include the piloting, evaluating, and rolling out of programmes related to HIV prevention and sexual and gender-based violence (SGBV), alcohol and drug abuse, and infection control within communities. Underserved at-risk populations1

The National Multi-Sectoral HIV Prevention Strategy recognises that the national HIV prevention response requires robust underlying systems to sustain achievements and investments. As such, the strategy calls attention to results in policy and legislation, coordination and management, strategic information, infrastructure, and human resources. Within these are opportunities to engage an expanded broad-base of Basotho stakeholders in HIV prevention.

include sex workers (SWs), men who have sex with men (MSM), and orphans and vulnerable children (OVC).

1 At-Risk Populations: these are populations most often considered to be at an elevated risk for HIV infection. These populations engage in illicit or socially stigmatized behaviours and are at disproportionately higher risk for HIV. HIV may spread rapidly in these populations due to more frequent participation in high risk behaviours such as unprotected anal and vaginal sex, sharing of injection equipment, and the overlap of risk behaviours and sexual networks (such as sex workers who use drugs or men who have sex with men (MSM) who sell sex). These at-risk populations include sex workers, clients of sex workers, substance abuse-using populations, herd boys, prisoners, people with disabilities, single, separated, or divorced adults, OVC, men and women who work away from home, MSMs who have sex with men and their male and female partners.

These include traditional, cultural, and religious leaders, the private sector, and people living with HIV (PLHIV).

The National Multi-Sectoral HIV Prevention Strategy must be seen as more than another planning document; it is a chance to revive HIV prevention efforts throughout the country. The strategies contained herein represent evidence-based, innovative approaches for stemming cases of new HIV infections. As such, it is a tool that will evolve and strengthen the engagement and participation of all stakeholders working in HIV prevention efforts throughout Lesotho.

Table of Contents

Preface

Acknowledgements

Executive Summary

Table of Contents

List of Figure

List of Abbreviations

1 Introduction

1.1 National Multi-Sectoral HIV Prevention Strategy, 2011 - 2015

1.2 Rationale

1.3 Development Process

1.4 A Combination Prevention Approach

1.5 Results-Based Management Approach

2 The HIV and AIDS Epidemic in Lesotho

2.1 The HIV Situation in Lesotho

2.2 Factors and Key Drivers Underlying New Infections

3 The National HIV Prevention Response in Lesotho

4 The National Multi-Sectoral HIV Prevention Strategy and Priorities

4.1 Guiding Principles

4.2 Strategies for Achieving Results

4.2.1 The Overall Goal

4.2.2 Strategic Framework and Results

4.2.3 Key Priorities

4.2.4 Objectives, Outcomes, Outputs, and Key Strategies and Activities

5.0. Resources required for full coverage

6.0 Implementation Arrangements

7.0 Conclusion

List of Figure

Figure 1: A Combination Approach for HIV Prevention

Figure 2: First and Second Tier Priorities in HIV Prevention*

Figure 3: Results for Intermediate Outcome 1.1.1

Figure 4: Results for Intermediate Outcome 1.1.2

Figure 5: Results for Intermediate Outcome 1.1.3

Figure 6: Results for Intermediate Outcome 1.1.4

Figure 7: Results for Intermediate Outcome 1.1.5

Figure 8: Results for Intermediate Outcome 1.1.6

Figure 9: Results for Intermediate Outcome 1.1.7

Figure 10: Results for Intermediate Outcome 1.1.8

Figure 11: Results for Intermediate Outcome 1.1.9

Figure 12: Results for Intermediate Outcome 1.1.10

Figure 13: Results for Intermediate Outcome 1.2.1

Figure 14: Results for Intermediate Outcome 1.2.2

Figure 15: Results for Intermediate Outcome 1.3.1

Figure 16: Results for Intermediate Outcome 1.3.2

Figure 17: Results for Intermediate Outcome 2.1.1

Figure 18: Results for Intermediate Outcome 2.1.2

Figure 19: Results for Intermediate Outcome 2.1.3

Figure 20: Results for Intermediate Outcome 2.1.4

Figure 21: Results for Intermediate Outcome 3.1.1

Figure 22: Results for Intermediate Outcome 3.2.1

Figure 23: Results for Intermediate Outcome 3.2.2

Figure 24: Results for Intermediate Outcome 4.1.1

Figure 25: Results for Intermediate Outcome 4.1.2

Figure 26: Results for Intermediate Outcome 4.1.3

Figure 27: Results for Intermediate Outcome 4.2.1

Figure 28: Results for Intermediate Outcome 4.2.2

Figure 29: Results for Intermediate Outcome 4.2.3

Figure 30: Results for Intermediate Outcome 4.3.1

Figure 31: Results for Intermediate Outcome 4.3.2

Figure 32: Results for Intermediate Outcome 4.4.1

List of Abbreviations

AIDS Acquired Immunodeficiency Syndrome

ALAFA Apparel Lesotho Alliance to Fight AIDS

ALE Association of Lesotho Employers

ANC Antenatal Clinics

ART Antiretroviral Therapy

ARV Antiretroviral Drug

BCC Behaviour Change Communication

BSS Behavioural Surveillance Survey

CBO Community-Based Organisation

CCAC Community Council AIDS Committee

CCSP Community Council Support Persons

CCP Comprehensive Condom Programme

CSSC Community Social Service Committee

CHAL Christian Health Association of Lesotho

CHW Community Health Worker

CRIS Country Response Information System

CSO Civil Society Organisation

CSW Commercial Sex Worker

DAC District AIDS Committee

DC District Council

DHMT District Health Management Team

ESP Essential HIV and AIDS Services Package

FBO Faith-Based Organisation

GBV Gender-Based Violence

GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria

GOL Government of Lesotho

HBC Home Based Care

HIV Human Immunodeficiency Virus

HR Human Resources

HRIS Human Resource Information System

HTC HIV Testing and Counselling

IDU Injecting Drug Use

IPV Intimate Partner Violence

KYE Know Your Epidemic

KYR Know Your Response

KYS Know Your Status

LAPCA Lesotho AIDS Programme Coordination Authority

LBTS Lesotho Blood Transfusion Services

LDHS Lesotho Demographic and Health Survey

LENASO Lesotho National AIDS Service Organisation

LENEPHWA Lesotho Network of People Living with HIV and AIDS

LGA Local Government Authority

LOMESHA Lesotho Output Monitoring System for HIV/AIDS

MCH Maternal and Child Health

M&E Monitoring and Evaluation

MOHSW Ministry of Health and Social Welfare

MOLGC Ministry of Local Governance and Chieftainship

MOPS Ministry of Public Service

MSM Men who have Sex with Men

NAC National AIDS Commission

NAS National AIDS Secretariat

NCPI National Composite Policy Index

NSP National HIV and AIDS Strategic Plan

OI Opportunistic Infection

OVC Orphans and Vulnerable Children

PEP Post-Exposure Prophylaxis

PEPFAR The President’s Emergency Plan for AIDS Relief

PLHIV People Living with HIV

PMTCT Prevention of Mother-to-Child Transmission

PWD People with Disabilities

RH/FP Reproductive Health and Family Planning

SADC Southern Africa Development Committee

SBCC Social Behavioural Change Communication

SGBV Sexual and Gender-Based Violence

STI Sexually Transmitted Infection

TB Tuberculosis

UNAIDS United Nations Programme on HIV and AIDS

UNGASS United Nations General Assembly Special Session

USAID United States Agency for International Development

WHO World Health Organisation

1 Introduction

1.1 National Multi-Sectoral HIV Prevention Strategy, 2011 - 2015

The National Multi-Sectoral HIV Prevention Strategy, 2011 – 2015, is a reference for the planning, implementation, evaluation, and resource mobilisation of the national HIV prevention response in Lesotho. The strategy offers guidance in scaling-up existing and effective HIV prevention programming interventions while developing new areas of the response. Outlining HIV prevention efforts between 2011 and 2015, the strategy details the behavioural, biomedical and structural interventions needed for a comprehensive yet targeted results-based combination prevention approach.

This strategy builds on a number of existing HIV and AIDS commitments. In 2001, Lesotho signed the United Nations Declaration of Commitment on HIV, which included a broad HIV prevention agenda. Lesotho has participated in regional initiatives and signed the Congo Brazzaville Declaration of Commitment to intensify HIV prevention efforts. Lesotho also participated in Southern African Development Community (SADC) HIV prevention initiatives, including the 2003 Maseru Declaration on HIV and AIDS.

Evidence-based and data-driven programming forms the basis of an intensified national results-based approach to HIV prevention. Each of the drivers of the HIV and AIDS epidemic identified within this strategy were drawn from current surveillance data, the 2009 Lesotho Demographic and Health Survey (LDHS), the 2009 Lesotho HIV Prevention Response and Modes of Transmission Analysis (Modes of Transmission Study), and a number of research studies conducted in Lesotho.

This strategy will guide the public, private, civil society, and NGO responses and development partners to HIV prevention, and complements the revised National HIV and AIDS Strategic Plan, 2006 – 2011, the Health Sector Policy on Comprehensive HIV Prevention, and the Essential HIV and AIDS Services Package. It should be read alongside the Situational Analysis for the National Multi-Sectoral HIV Prevention Strategy, 2011 – 2015, which was developed to guide this strategy. Key findings from this Situational Analysis are included in the introductory sections of this strategy.

1.2 Rationale

Lesotho is one of the countries worst affected by HIV and AIDS worldwide, with 23% of adults now living with HIV. HIV prevalence peaks to almost 42 % among some sub-populations in the country. While commitments relating to treatment, care, support, and impact mitigation remain vitally important to the national HIV and AIDS response, an intensified HIV prevention response is recognised as a top priority by the Government of Lesotho (GOL) and internal and external partners. This prevention strategy proposes an aggressive goal of a reduction in the level of new HIV infections by 50% by 2015.

In order to achieve this goal, the main drivers of Lesotho’s severe, generalised epidemic must be addressed, including the heterosexual transmission of HIV within serial, multiple, and concurrent partnerships, and vulnerability to HIV infection and low and inconsistent condom use during higher-risk sexual acts. A number of factors have an effect on these drivers and must also be considered in a comprehensive response. These include population mobility attributed mainly to domestic and cross-border migration, low-levels of in-depth HIV knowledge, the presence of sexually transmitted infections, alcohol and drug abuse, social and gender norms, and gender-based violence and inequality.

1.3 Development Process

Under the guidance and supervision of the National AIDS Commission (NAC), and in consultation with the Prevention Strategy Core Team, the Prevention Thematic Team, and the High-Level Forum, this document was developed through an extensive process of consultation and review at the community, district and national levels. The phases of the process were as follows:

An inception report was developed at the beginning of the process which outlined the planned activities and included the tools, guidelines and requirements necessary for the development of the strategy.

A situation analysis was drafted which gave an overview of the epidemic and the current national HIV prevention response.

Fifteen district and community level consultations were undertaken across the country utilising the District Councils (DCs), District AIDS Committees (DACs), Community Councils (CCs), and Community Council AIDS Committees (CCACs). A number of other stakeholders participated, including representatives from public, private, civil society, and NGO networks such as health care workers, faith leaders, business leaders, traditional leaders, and programme managers and other communities that work in HIV prevention.

Consultations were also conducted at the national level in Maseru in order to solicit the feedback and guidance on the strategy from Government ministries, the private sector, academia, civil society, and HIV and AIDS Thematic Working Groups.

Upon completion of the consultations, several versions of the strategy were circulated for review, each incorporating a further level of input from local and external stakeholders, which resulted in the validation of the final version of the strategy.

1.4 A Combination Prevention Approach

Combination prevention is a human rights-based approach (UNAIDS Prevention Reference Group, 2009). Its aim is to have the greatest sustained effect on reducing the number of new HIV infections through the selection of appropriate interventions for the epidemiological and social context. This strategy utilises a combination prevention approach, which is predicated upon Knowing Your Epidemic (KYE), and Knowing Your Response (KYR). The combination approach acknowledges that HIV incidence is affected by various economic, biomedical, legal, political, cultural and psychosocial factors that must be analysed and addressed at systems and programme levels.

A combination prevention approach stresses the importance of an integrated, comprehensive HIV response, with behavioural strategies to address risky behaviours, biomedical interventions to prevent infection or reduce infectiousness, and structural strategies to change the context that contributes to vulnerability and risk of HIV at a number of levels.

Behavioural elements of this strategy include efforts to change the practices of individuals in relation to sexual risk and demand for HIV prevention services and products. Methods address the reduction of the sexual transmission of HIV through communications delivered through a range of channels, with targeted messages designed to move individuals towards desired behaviours. Other behavioural elements include HIV testing and counselling (HTC) and the mitigation of substance abuse.

Biomedical elements within this strategy include a four-pronged strategy to prevent PMTCT, the promotion of male circumcision, condoms, sexually transmitted infection (STI) management, reproductive health and family planning (RH/FP), and Positive Prevention interventions. Other key biomedical interventions include preventing HIV transmission within medical settings through blood and injection safety, and the proper disposal of hazardous materials, such as used syringes and blood products.

The range of structural interventions includes addressing harmful social norms relating to gender, sexual and gender-based violence (SGBV), stigma and discrimination, and sexuality.

Approaches to addressing these societal level factors are integrated throughout the objectives through key outputs and strategies. A number of policies, legislative and infrastructural components are also outlined for structural level impact.

Achieving results within a combination approach requires robust coordination, management, and information systems, as well as the resources and capacity to execute interventions. This strategy reinforces the need to strengthen the supportive systems necessary for an effective response among stakeholders from the government, CSO, NGO, donor and private sectors.

Figure 1: A Combination Approach for HIV Prevention

A Combination Prevention Approach

Behavioural Biomedical Structural

Reduction of sexual transmission HIV testing and counselling Reduction of substance abuse

Male circumcision

PMTCT

STIs Condoms Positive Prevention RH/FP integration Prevention of medical transmission

Gender norms Traditional and cultural practices Sexual and gender-based violence Socio-economic factors Stigma and discrimination

Across all areas:

Social and behavioural change communications Service delivery Policy, legislation, and advocacy Measurable referrals Coordinated management of programmes and stakeholders Capacity building Resource mobilisation

1.5 Results-Based Management Approach

With the development of the National Strategic Plan for HIV and AIDS, the GOL moved towards a results-based management approach for the national response. While NAC, the Ministry of Health and Social Welfare (MOHSW), and the many organisations that implement the national HIV prevention response have been working to produce measurable results, the emphasis has often been on managing inputs and activities. As a result, most HIV prevention organisations have not been able to show progress towards achieving key outcomes in terms of changes in reduction of HIV risk or vulnerability among key populations. While it is still vital to demonstrate progress in relation to processes, activities, and outputs, a shift to a results-based management approach places greater emphasis on measuring the effects of outputs and activities in terms of outcomes and overall impact.

The results-based management system outlined in this strategy sets out clear programme and management objectives for all organisations involved in the national response, and establishes indicators to monitor and assess progress in meeting them. Interlinking chains of results are defined, which stretch from the level of programme activities through to output level results and outcome level results, and ultimately to impact level results.

While the move towards results-based language signalled an important step forward for the Lesotho national response, the challenges of measuring results, let alone managing for results, should not be understated. Significant shifts are required within the institutional cultures and work practices within NAC, line-ministries and an array of public, private and civil society bodies.

It is likely that these changes will take some time, but the fact that this HIV prevention strategy is articulated in results-based language marks yet another important step in this direction.

2 The HIV and AIDS Epidemic in Lesotho

The following section highlights the key patterns and dynamics that drive Lesotho’s epidemic. A more comprehensive analysis of the HIV situation in Lesotho can be found in the Situation Analysis for the Lesotho HIV Prevention Strategy, 2011 – 2015, the document that supports the National Multi-Sectoral HIV Prevention Strategy.

2.1 The HIV Situation in Lesotho

Lesotho is currently experiencing one of the most serious HIV epidemics in the world, although there is evidence that the epidemic has somewhat stabilised in the past few years. The HIV prevalence rate in 2009 among Basotho aged 15-49 was 23 % and in 2007, annual adult HIV incidence was 1.7% or approximately 21,000 new cases that year.

The 2009 Lesotho Demographic and Health Survey (LDHS) data indicate a rapid rise in HIV prevalence among young people, particularly young women. The total number of HIV-infected females aged 15-49 is 27%, but significantly lower at 18% for men the same age. By age 20-24, approximately 24% of women are infected; prevalence increases to 35% for the age cohort 25- 29 and peaks at 41% and 42% for women throughout their thirties. Male prevalence lags behind female prevalence by about five years, but similarly reaches about 40% among men aged 30-

35. With such high average levels of prevalence nationally, the pool of at-risk individuals is likely at or near saturation among adult men and women aged 25-44.

HIV prevalence patterns differ by urban-rural residence and throughout the country’s districts.

Basotho men and women who reside in urban areas have higher rates of HIV infection than their rural counterparts. This is particularly so for urban women, with an infection rate of 31% as compared to 25% for females who reside in rural areas. The epidemic is almost uniformly severe in each of the ten districts in the country. Butha-Buthe and Thaba-Tseka have the lowest rates at 21% each, and Maseru peaks at 31%.

Marital status seems to be correlated closely to HIV status. Rates are high among widows (60%) and widowers (62%), and among both men and women who are divorced or separated (59% for women and 31% for men). HIV infection rates are also high among Basotho who are currently married or in union, at 26% for women and 31% for men.

Mobility among men is correlated to HIV prevalence. Men who have spent more time away from home during the past twelve months have higher infection rates, as do men who have been away from home for more than one month (2009 LDHS).

Children continue to be vulnerable to HIV. The 2009 Modes of Transmission Study estimates that annual incidence in children has dropped to 0.17%, in part attributed to the uptake of PMTCT services to 31% of pregnant women by 2007, and the overall decrease in incidence in adults. Some children might be infected from early sexual debut. According to the 2009 LDHS, 8% 9% of young women and 22% of young men have had sex before the age of 15, with these percentages rising to 47% of young women and 63% of young men who have had sex before the age of 18. Only 24% of children under the age of 18 live with both of their parents. 33% live with their mothers only, 5% with their fathers only, and 36% live with neither, and are considered to be “fostered”. 20% of Basotho children under the age of 18 have lost one parent, and 7% have lost both. The 2009 Lesotho National Estimates state that there are 21,000 HIV-infected children under the age of 15 in Lesotho, and 122,000 children orphaned due to HIV and AIDS.

As per the results of mathematic modelling within the Modes of Transmission Study, heterosexual contact is the primary driver of the epidemic in Lesotho. Single partnering contributed between 35-62% of new infections in 2008, with multiple partner behaviours between 32-59%. Three to four per cent of new infections might be attributed to MSM, and HIV transmission linked to unsafe medical practice is less than 1% of total annual incidence. HIV transmission through blood transfusion is 0% because all blood is screened for HIV, although this does not capture potential false negatives.

2.2 Factors and Key Drivers Underlying New Infections

There are multiple layers of drivers of the epidemic, from the proximal drivers such as multiple and concurrent partnerships through to the more distal drivers such as patterns of migrant labour, and the broader macro-economic situation that may affect vulnerabilities for many Basotho. The following describes some of the factors and dynamics that facilitate the transmission of HIV in Lesotho.

Multiple and concurrent relationships

Sexual concurrency, often in the form of long-term secondary partners, is exceptionally high in Lesotho. The prevalence of multiple and concurrent partnerships is estimated at 24%, compared to 10% in the region, and in some studies up to 36% of individuals report having multiple and concurrent partnerships. The 2009 LDHS indicates that multiple and concurrent partnerships are prevalent throughout Lesotho. 26% of women and 45% of men reported having two or more partners during the past twelve months with (3%) of men reporting having paid for sex during the previous year. Although frequency of multiple and concurrent partnerships appears to be declining, multiple data sources confirm that such partnerships remain at a high level, and are legitimised through deep-rooted traditions that encourage many sexual partners or polygamy. There are a number of different types of multiple and concurrent relationships, and each are different in terms of motivations, practices, and duration.

Low and inconsistent condom use

Many Basotho men and women engaging in sex in the context of a high background level of HIV risk do not protect themselves by using condoms. Of females and males aged 15-49 who had two or more sexual partners during the past twelve months, 38% of women and 51% of men reported using a condom. Among never-married women and men aged 15-24 who had sex in the past twelve months, 65% used a condom at last sexual intercourse, Among youth aged 15-24 who reported having two or more partners during the previous 12 months, 45% of women and 60% of men reported condom use during the last sexual act. (2009 LDHS). Although there is widespread condom distribution, many communities perceive condoms as not readily available and accessible. Urban and rural condom coverage is estimated at 69% and 33%, respectively (2009 PSI condom distribution survey).

Personal knowledge of HIV serostatus

The percentage of Basotho who have taken an HIV test and have received their results has greatly increased since the country has expanded the availability of HIV testing and counselling services, supported by intensive education and demand creation communications. Ninety three percent of Basotho women aged 15-49 know where to get an HIV test and 66% have been tested and received their results. Of these, 42% were tested during the previous 12 months. The same figures are significantly lower for men. For men the same age, 81% know where to get an HIV test and 39% have been tested and received their results, of whom 25% did so during the past 12 months. Although only 43% of women aged 15-19 report having been tested and received results, this figure rises to 75% by the age of 20-25. Only 26% of men aged 15-25 have been tested and received their results.

Male circumcision

According to the 2009 LDHS, 52% of men aged 15-49 report being circumcised. Men aged 15- 19 have the lowest rates at 27%. Although this might be attributed to a decrease in the practice of circumcision, it is possible that youth are circumcised at a later age (62% of men age 20-24 are circumcised). Circumcision rates are considerably lower among urban men than rural men (34% and 59%, respectively), and the prevalence of circumcision decreases significantly among men within the highest wealth quintiles (74% of men in the lowest quintile compared to 29% in the highest). Although in clinical trials circumcision has shown to have a protective effect against HIV infection in men, the 2009 LDHS data indicate that Basotho men who are circumcised have higher HIV prevalence rates than uncircumcised men: 21% of circumcised men are HIV-infected, compared to 16% of uncircumcised men. This can partially be attributed to the Lesotho custom of conducting male circumcision at a later stage in life when individuals have already been exposed to the risk of HIV infection. In addition the traditional practice of male circumcision that partially removes the foreskin, and thus traditional male circumcision does not seem to have the same protective and hygienic effect as clinical circumcision. Only the 30% of men circumcised at health facilities can be considered to have the beneficial protection conferred by male circumcision (2009 LDHS).

Sexually transmitted infections

According to the 2009 LDHS, among Basotho age 15-49 who have ever had sexual intercourse, 15% of women and 13% of men reported having an STI, an abnormal discharge, or a genital sore or ulcer. STIs are associated with HIV prevalence in Lesotho. For women, 43% who reported having an STI or symptoms were HIV infected, compared to those who reported no STI, at 29%. For men, these figures are 33% and 18%, respectively. The 2009 HIV sentinel surveillance among STI clients for two sites indicated an even higher HIV prevalence among STI clients than the 2009 LDHS, at 55% overall. HIV prevalence was lowest among 10 -20 year olds, at 40%, and peaked to 65% for 31-40 year olds, then dropped to 60% for adults between the ages of 41-50.

Late initiation of ART for HIV-Infected Basotho

The timely initiation of antiretroviral therapy (ART) is critical in HIV prevention because a dramatically lowered viral load suppresses the onward transmission of HIV to other people when adherence levels are high. Lesotho’s ART guidelines, which were aligned to international guidelines in 2007, adjusted eligibility from a CD4 count of 200 to 350. As such, people could begin treatment before they became ill and more infectious. However, as per the 2009 Mid- Term Review of the National HIV and AIDS Strategic Plan, although the GOL dramatically scaled up its ART treatment services, by 2008 only 25% of eligible adults and 26% of eligible children were receiving ART, and adherence and delivery continue to pose grave challenges.

Behavioural disinhibition related to substance abuse

Studies have documented the link between alcohol and drug abuse and increased risk of HIV infection. In addition, alcohol abuse among HIV-infected individuals is associated with poor ART adherence, with implications for the onward transmission of HIV. In Lesotho, while there is little data on alcohol abuse, practices, and their relationship to HIV risk, the 2009 LDHS showed that the HIV prevalence rate among men who reported ever drinking alcohol is 23%, compared to 16% of those who never drank alcohol. There is little data on drug abuse and HIV risk in Lesotho, although some data indicate that the use of cannabis (matekoane) is widespread.

Labour migration

A major factor contributing to HIV risk and multiple and concurrent partnering is domestic and international labour migration, which plays a substantive social and economic role in the lives of most Basotho: more than 255,000 individuals have emigrated, mostly for work and mainly to South Africa. Other manifestations of labour migration include the apparel, transportation, and construction industries, as well as uniformed personnel and the informal cross border trade.

Furthermore, as a result of having a partner “left behind”, migration increases risk to both partners, because women as well as men become infected with HIV through sexual relationships outside of their primary ones. In Lesotho, the partner at home is most often female:

the 2009 LDHS indicates that 36% of households in Lesotho are female-headed, partly attributed to labour migration.

Gender and sexual and gender-based violence

Gender dynamics can exacerbate HIV risk, for example, certain manifestations of male and female norms, behaviours and practices create vulnerability to HIV infection. The 2009 LDHS provides information on female empowerment and decision making within the home. Sexual and gender-based violence also increases the risk of HIV infection. In regards to domestic violence and justification for wife beating, 37% of women age 15-49 agreed with at least one reason that justifies hitting a wife (the reasons include burning food, arguing with the husband, going out without telling him, neglecting the children, and refusing to have sexual intercourse). The corresponding response from men age 15-49 was 48%. Among men aged 15-49, 26% thought that men are justified in withholding financial support from his wife if she refused to have sex with him, and 16% thought forced sex was justifiable (2009 LDHS). A study looking at sexual violence against women in Lesotho indicated that 61% of women reported having experienced sexual violence at some point in their life, with 40% reporting coerced sex, 50% assault, and 22% rape.

Traditional and cultural practices

Within the context of HIV and AIDS, some traditional and cultural practices can be harmful and increase risk and vulnerability to HIV infection. In Lesotho, examples include the practice of chobeliso, or eloping that involves abduction, rape, and marriage; and the practice of ho kenela, or wife inheritance, which may place families at-risk if the practice is non-consensual or family members are infected with HIV. Other practices that might create risk and vulnerability to HIV infection include domestic violence and dry sex. Beliefs in proverbs such as, “monna ke mokopu oa nama, mosali ke cabbage oa ipopa” (man is like a pumpkin and spreads, woman is like a cabbage and stays put), can serve to reinforce the acceptability of multiple and concurrent partnerships. Other traditional and cultural practices need to be assessed for their positive contribution, for example in relation to collective decision making, some specific roles of traditional healers, and practices that promote social cohesion and social capital.

Hard-to-reach populations

Only 24% of Lesotho’s population lives in urban areas. The 76% of people who live in rural areas have less access to services and in some cases experience poorer health outcomes than their urban counterparts. The challenges for health service delivery are in part due to the difficulty of accessing hard-to-reach people who live in scattered pockets across a rugged and sometimes difficult mountainous terrain.

Stigma and discrimination

Stigma and discrimination can be inculcated throughout a society within a number of levels, and can greatly reduce the effectiveness of HIV prevention initiatives. Stigma and discrimination influence how the environment is experienced and acted upon by individuals, especially with respect to caretaking within the family. At the community level, blame and punishment can be manifested toward those believed to have brought shame on their families and the community.

At the political level, policies and legislation can be passed that either aim in theory to protect the rights of society (e.g. compulsory testing and notification), or can protect the rights of PLHIV (e.g. workplace anti-discrimination policies). The 2009 LDHS indicates that while many Basotho have accepting attitudes towards PLHIV, there are still considerable reservations towards interacting with PLHIV on a daily basis. Forty two percent of women aged 15-49 expressed accepting attitudes to PLHIV on all four indicators – caring for a family member with HIV in the home, buying fresh vegetables from an HIV-infected shopkeeper, saying that an HIV-infected female teacher who is not sick should continue teaching, and would not keep secret the HIV status of a family member – while only 32% of men the same age did so.

3 The National HIV Prevention Response in Lesotho

Under the principles of KYE and KYR, the national HIV prevention response utilises a process that enables the country to match and prioritise responses to the drivers of the epidemic. A comprehensive analysis of the HIV situation in Lesotho can be found in the Situational Analysis for the Lesotho HIV Prevention Strategy, 2011 – 2015, the document that supports the National Multi-Sectoral HIV Prevention Strategy. The following presents the highlights of the national HIV prevention response in Lesotho.

Behavioural initiatives

There are numerous initiatives in Lesotho that address the reduction of the sexual transmission of HIV, particularly through social behavioural change communication (SBCC) programmes.

These include mass media campaigns, life-skills curricula in schools, peer education, and community engagement activities implemented by a range of CSOs, NGOs, PLHIV support groups, faith-based networks, and the private sector. The number of Basotho who know their HIV status has grown dramatically through the implementation of the Know Your Status (KYS) campaign which aimed to provide HTC to every Mosotho over the age of 12 years. Between 2007 and 2008, HTC facilities increased from 163 to 204. Although alcohol and cannabis abuse are the most common forms of substance abuse in Lesotho, there are few organisations addressing these issues. The Blue Cross manages a rehabilitation centre in Thaba-Bosiu and a few local NGOs conduct substance abuse education in schools.

Biomedical initiatives

Biomedical interventions in Lesotho include the roll out of Prevention of Mother-to-Child (PMTCT) services in all ten of Lesotho’s districts in public and faith-based facilities, including MOHSW and the Christian Health Association of Lesotho (CHAL) facilities. PMTCT coverage rates have increased from 58.2% in 2007 to 71% in 2009. Another biomedical initiative is male circumcision, and the MOHSW is investigating the possibility of implementing adult and neonatal male circumcision initiatives in Lesotho. To date, the Male Circumcision Task Force has drafted a policy, strategy, and implementation plan for safe, facility-based circumcision. The integration of RH/FP services into HIV prevention is increasing in Lesotho, with PMTCT/RH/FP initiatives underway. Condom promotion and distribution is a national initiative, with male and female condoms supplied through a mix of social marketing, free public sector, and private sector distribution and retailing systems. Lesotho is in the process of rolling out facility- and community-based Positive Prevention services, which are critical for reducing the risk of on-going HIV transmission. The Lesotho Blood Testing Services (LBTS) works on the prevention of HIV infection through medical transmission through its blood safety programme. Other prevention efforts with respect to medical transmission include the roll out of post-exposure prophylaxis (PEP) in facilities where there is the potential for exposure through occupational hazard and sexual assault.

Structural initiatives

Many organisations that implement HIV prevention initiatives mainstream gender, male involvement, SGBV, and stigma and discrimination into their programming. This results in the inclusion of topics on gender within community dialogues as implemented by CSOs, the targeting of male partners within PMTCT services, and loan schemes targeted to female caregivers. In regard to traditional and cultural norms, Lesotho is in the process of expanding dialogue with traditional and cultural leaders. PLHIV network organisations are addressing stigma and discrimination by building linkages among organisations that provide services to PLHIV. Particular areas of concern are discrimination in the workplace, in school/educational settings, and against certain population groups, including sexual minorities, sex workers, and inmates.

Cross-cutting systems strengthening issues

Policy and Legislation: A number of key policies have been passed to guide the national HIV prevention response. For example, in 2006, a revised National HIV and AIDS Policy was passed after a National Joint Review identified needs, challenges, and gaps in the 2000 HIV and AIDS policy and in the legislative framework. Lesotho’s legislative policy framework (2000) sets the agenda for legislative review to enact specific policies to protect vulnerable groups, children and women and discrimination against PLHIVs. Since then, numerous policies and laws have been drafted, including the recent 2008 Lesotho HIV and AIDS Bill, the Legal Capacity of Married Person's Act, the Sexual Offences Act (2003), and the amended Labour Code No. 5 of 2006.

Coordination and Management: At the national level, Lesotho has adopted a multi-sectoral approach in the coordination and implementation of the national response. This includes the establishment of the National Partnership Forums, HIV and AIDS Thematic groups (e.g.