Background

Lesotho is one of the countries hardest hit by HIV, with the tragic distinction of having the second highest HIV prevalence in the world after Swaziland. HIV prevalence[1] is currently estimated at 25%.

The epidemic is mostly heterosexual and the risk factors include both cross border and internal migration, and high risk sex. Lesotho’s 2014 Demographic and Health Survey (LDHS) reports prevalence among women to have increased from 26% in 2004 to 30% in 2014, while prevalence among men has remained stable at 19% over the same period. HIV prevalence among high risk populations ranges from 72% in sex workers, to 43% in factory workers and 33% in men who have sex with men. In 2015 there were some 310,000 people living with HIV, of whom 290,000 were adults and 13,000 children (up to 14 years of age). There are an estimated 73,000 orphans (aged up to 17 years) in Lesotho because of AIDS.

While HIV incidence is declining (from 30,000 new infections in 2005 to 18,000 new infections in 2015), high levels of poverty and inequality, due to political instability and a struggling economy, have left the country very dependent on donors for financial support. Although progress has been made in some areas, serious challenges remain.

[1] The international standard, also used in Lesotho, is to estimate HIV prevalence among those aged 15 – 49.

 

The Government of Lesotho’s revised National Strategic Plan for HIV and AIDS 2011/12 – 2017/18 aims to halve new infections by 2020 by focusing on four core programmes:

  • treatment, care and support;
  • EMTCT (elimination of mother to child transmission);
  • VMMC (voluntary male medical circumcision)[1], condom promotion and distribution;
  • prevention of new infections among key populations through targeted programmes and other critical enablers and development synergies.

In 2016 Lesotho became the first sub-Saharan African country to implement the new WHO approach to HIV treatment: Test and Treat – patients testing positive start treatment immediately rather than waiting for their blood CD4 count to drop below a certain threshold. This has resulted in a much more cost-effective health service delivery approach, i.e. less testing, fewer appointments etc.

However, progress towards achieving internationally agreed targets seems to be mostly off track. Initial gains in, for example, reducing mother to child transmission (MTCT) are being eroded, and there are major challenges with respect to HTC (HIV Testing and Counselling), ART (including paediatric ART coverage) while prevention of MTCT coverage is also slowly declining.

Lesotho has now set some ambitious new targets, known as 90-90-90 by 2020:

  • 90% of all people living with HIV will know their HIV status;
  • 90% of all people diagnosed with HIV will receive sustained antiretroviral therapy; and
  • 90% of all people receiving antiretroviral therapy will have durable suppression.

While the Government has increased its contribution towards funding the national HIV response from about 26% in 2014 to 34% in 2015 (with projected additional commitments in 2016, 2017 and 2018), Lesotho remains heavily dependent on external donors. The major donors in Lesotho are the Global Fund (primarily budget support into the Ministry of Finance and Development Planning), the (US) President’s Emergency Plan for AIDS Relief (PEPFAR: service delivery focusing on the five lowland districts of Maseru, Mafeteng, Mohale’s Hoek, Leribe and Berea, in which 72% of the population reside), the US Centres for Disease Control (CDC), the EU and the UN family.

Lesotho’s ranking as a Middle-Income Country means it pays more for its antiretrovirals (ARVs): M8,000 for a patient’s annual supply of the ARV, Atripla, whereas Low Income Countries pay about M1,300. Between 2014/15 and 2017/18, the HIV response in Lesotho will cost an estimated US$ 593m (care and treatment accounting for the largest share at 36% while behavioural prevention is <5%). National and international commitments are estimated at US$ 344m, leaving a funding gap of US$ 249m. At the same time, financial resources from international donors and other sources are projected to decline by 25% in total. The largest anticipated unfunded programmes across the years are care and treatment, and impact mitigation. Securing funding to fill this gap will be vital to ensuring hard won progress in Lesotho’s response to HIV is not reversed.

 

[1] This is the standard term, although inclusion of the word ‘male’ is superfluous.

[2] Source: AIDS Healthcare Foundation (AHF), a global programme with its headquarters in the United States.