Lesotho

Ahead of the mid-term review of the 90–90–90 treatment targets in 2017, Marc Angel, Chair of Foreign Affairs and Development Committee of the Luxembourg Parliament and UNAIDS Champion for the 90-90-90 targets, undertook a multicountry fact-finding visit to Botswana, South Africa and Lesotho from 17 to 21 April. The visit provided Mr Angel with the opportunity to conduct high-level political advocacy to continue and accelerate momentum towards achieving 90–90–90 by 2020.

The fact-finding visits to southern Africa confirmed the importance of intensifying efforts to increase the proportion of people living with HIV who know their HIV status. In addition, the visits highlighted the central importance of community health workers, both to achieve the 90–90–90 targets and to ensure national preparedness to identify and address emerging health challenges.

What are the 90–90–90 targets?

• By 2020, 90% of all people living with HIV will know their HIV status.
• By 2020, 90% of people who know their HIV-positive status are accessing treatment.
• By 2020, 90% of all people on treatment have suppressed viral loads .

Modelling suggests that achieving these targets by 2020 will enable the world to end the AIDS epidemic as a public health threat by 2030, which in turn will generate profound health and economic benefits

Find out more here

In each country he visited, Mr Angel met with leaders from government and civil society to witness how 90–90–90 is being adopted in high-burden countries. He also visited numerous health facilities and community-based projects to experience first-hand how 90–90–90 is being implemented on the ground. All three countries have adopted and implemented the World Health Organization guidelines for universal HIV testing and treatment for all people living with HIV and have strong political commitment to reaching 90–90–90. The three ministers of health from each country agreed that community health workers must be the central mode of delivery for 90–90–90.

More than 50 000 people in eastern and southern Africa received HIV testing and counselling services as part of national campaigns held between 17 and 30 November. On 1 December, World AIDS Day, countries unveiled the number of people tested during the campaigns, which took place in Botswana, Ethiopia, Lesotho, Namibia, South Africa and United Republic of Tanzania.

While the campaigns sought to reach the general population, some countries focused on reaching populations at higher risk of HIV infection, including young people, women and migrants.

Ethiopia held a one-day campaign in Gambella, which has the highest HIV prevalence in the country, at 6.5%, according to the 2011 Ethiopian Demographic Survey. Botswana provided HTC services at 10 testing sites in Maun District, with a special focus on couples and young people. Lesotho undertook a two-week nationwide campaign focusing on young people, migrants, men and traditional healers. Namibia held the testing in Katutura—a township of the capital Windhoek—to reach underserved communities in informal settlements.

Communities, non-profit organizations and national partners supported the campaigns by mobilizing communities, procuring test kits or distributing HIV information materials and commodities. The campaigns also ensured that people who tested positive for HIV were referred and linked to HIV treatment and care services.

The number of people tested during the campaigns reaffirms the strong commitment of countries to accelerate community action and galvanize the active involvement of young people and networks of people living with HIV to end the AIDS epidemic by 2030.

Oral pre-exposure HIV prophylaxis (PrEP) has been shown to be up to 90% effective in preventing HIV infection among people who take it consistently. However, the United States of America is the only country in which PrEP is licensed and recommended for use within HIV prevention programmes. 

In order to find ways to bridge the gaps between evidence and policy-making processes, UNAIDS, AVAC and WHO organized a meeting during the 2014 HIV Research for Prevention (HIV R4P) conference, which is taking place from 28 to 31 October in Cape Town, South Africa. HIV R4P is the world’s first scientific meeting dedicated exclusively to biomedical HIV prevention research.

Participants

The meeting brought together representatives of ministries of health and national AIDS councils from Kenya, Mozambique, South Africa, Uganda and Zimbabwe, PrEP researchers and participants from research and demonstration sites where PrEP is currently being delivered, funders and drug manufacturers, and HIV activists.

Key messages

• PrEP is being used in several demonstration projects across eastern and southern Africa, covering a wide range of populations, including serodiscordant couples in Kenya and Uganda, sex workers in Zimbabwe and men who have sex with men in Kenya and South Africa.
• In order to be used more widely, PrEP must be part of a comprehensive prevention strategy with associated milestones and success indicators that have been defined with policy-makers. The Kenyan Prevention Roadmap already includes the possibility of PrEP.
• Costs and cost-effectiveness models remain key, as are the selection of populations for which PrEP should be offered and the choice of an appropriate delivery model. The Sisters clinics, which provide a dedicated service for sex workers in Zimbabwe, are acceptable to many sex workers and fit within a government strategy.
• The early stopping of the PROUD PrEP study demonstrates that within the sexual health services of the United Kingdom of Great Britain and Northern Ireland there is a strong demand for PrEP and that it is feasible to identify people at greatest risk.
• Demand is now beginning to grow in African communities and needs to be stimulated among those who would most benefit and would be most likely to use PrEP.
• Policy-makers in health and other government departments need more information on PrEP presented in a way that they can use, as well as opportunities to discuss their specific concerns, for example on PrEP safety studies or measures to improve adherence.
• More needs to be understood about the costing of PrEP. This demands greater understanding of who would use PrEP, how they would use it and where they would access it.

How to realize Africa’s potential for the future of all its peoples and build international support for the continent’s development were key questions explored in the first session of the Africa Rising Forum held this week in New York.

Taking place at the Africa Center and organized by the Mo Ibrahim Foundation, the 22 September event brought together a number of African heads of state, United Nations partners, and leaders from African civil society and the business community.

They examined how to move beyond simply talking about the need for broad-based economic transformation and sustainable development to taking concrete steps to make them a reality, especially with regard to the post-2015 development agenda. 

A session on ensuring shared prosperity looked at ways to improve investment and resource mobilization, champion entrepreneurship and ensure social protection. Another stressed that development cannot be achieved without the existence of good governance, peace, security and respect for human rights.

It was agreed that ensuring health for all was a critical facet of Africa’s rise, and that ending the AIDS epidemic as a public health threat by 2030 now a realistic goal. There was also a consensus that the continent’s rise should not only be measured in terms of overall wealth generated but by the inclusiveness of socioeconomic progress that leaves no one behind.

Learners participating in a ‘Positive Speaking’ intervention, in Luanda, Angola
Credit: UNESCO

Students and teachers in four southern African countries are benefiting from an ambitious HIV programme spearheaded by UNESCO. From its start in 2008, the programme was designed to strengthen the education sector’s AIDS response in Angola, Lesotho, Namibia and Swaziland.   

Called ‘Building knowledge, skills and hope: HIV and AIDS education for African children’, the three-year project has encompassed improving the curriculum and learning materials about HIV. It has also focused on supporting teacher training with better programme and policy guidance. The programme aimed to strengthen care and support systems for learners and education personnel affected by HIV as well as to improve the delivery of AIDS education in hundreds of schools. 

Implemented by UNESCO and financed by the Virginio Bruni Tedeschi Foundation, the project was carried out under the UNAIDS Global Initiative on Education and HIV and AIDS (EDUCAIDS) and reinforced ongoing work in each country’s ministry of education.

According to UNESCO the result has been the repositioning of the education sector at the centre of the national AIDS response in all four countries. Reforms are underway in all project countries to integrate HIV and sexuality education into the curricula of schools and teacher training institutions.   

The initiative has led to a number of innovations such as the establishment of the first national networks of teachers affected by HIV. “Since this initiative was launched, we share our experiences, our fears, our hopes and our dreams together,” said Nelao Martin, a teacher living with HIV and a member of the EduSector Support Network on Health and HIV in Namibia. “In the past, someone somewhere has necessarily been through the same difficulties and managed to deal with it.”

The first support groups for children and adolescents affected by AIDS have been established. Also, in partnership with associations of people living with HIV, new approaches have been used to reach out to positive learners in schools. ‘Positive Speaking’ sessions were introduced whereby personal testimonies and experiences of young, openly HIV-positive facilitators allowed pupils to ‘put a face’ to the virus.  

Nkuebe Peete, an HIV-positive 23 year-old living in Lesotho has taken part in such interventions: “I am proud to share my story and experience with younger people so that they do not make the same mistakes that I made and become supportive to those who live with HIV. This has given a new meaning to my life. I now have the feeling of being a much better person than before.”

In addition, innovative teaching and learning materials have been developed such as the series of speaking books on HIV for primary pupils in Swaziland. Most materials for the sensitization of older students have been developed by the learners themselves in creative and interactive ways. One particular approach involved national and regional ‘PhotoVoice’ exhibitions which highlighted testimonies of HIV-positive learners and teachers. In total, project activities have reached more than 4 000 schools, 17 000 teachers and nearly half a million learners.

Building on the groundwork laid by the project new initiatives are being developed. For example, in May 2011 Namibia’s ministry of education mandated and budgeted for the introduction of full-time teachers dedicated solely to life skills education, guidance and counselling in all primary and secondary schools. 

Lesotho and Swaziland are about to adopt policies that recognize the impact of AIDS on their education systems. Such policies call for the integration of strategies for prevention and care adapted to the needs of learners and teachers. Similar efforts have been initiated in Angola, which is addressing the formulation of an education sector strategy and policy on HIV.  

Project partners believe the programme has contributed significantly to improving the AIDS response in the education sectors in all four countries. According to Majoele Likonelo Hlasoa, Director of Planning at the Ministry of Education and Training in Lesotho, “When I first joined the Ministry of Education, I did not understand what the education sector could and should do about HIV, which I  considered then as a health issue falling fully under the responsibility of the Ministry of Health. Since I have been exposed to the EDUCAIDS framework for action, I have changed my mind and have a real understanding of the issues at stake.”

A version of the story was first published at unicef.org

Ann M. Veneman visits clients at a children's clinical centre built by Baylor College of Medicine and Bristol-Myers Squibb in Maseru, Lesotho, where paediatric and family HIV care and treatment services are provided to young children and their caregivers.

During a recent visit to Lesotho, UNICEF Executive Director Ann M. Veneman launched Facts for Life, a publication that delivers life-saving information to families and communities on how to prevent child and maternal deaths, diseases, injuries and violence.

“Education is key”, said Ms Veneman. “Through simple messages, Facts for Life aims to bring vital knowledge to parents and caregivers, who are the first line of defence in protecting children from illness and harm.”

Circulated worldwide

Some 15 million copies Facts for Life have reached billions of people since its first publication in 1989. It is a co-publication by UNICEF, WHO, WFP, UNESCO, UNFPA, UNDP, UNAIDS and the World Bank, and provides practical advice on pregnancy, childbirth, major childhood illnesses, child development, early learning, parenting, protection, care and support for children.

New chapter on child protection

The publication includes a chapter on managing HIV. It promotes early diagnosis in children, effective treatment and anti retroviral therapy when prescribed. Currently most HIV-positive children are given such treatment after the age of five, when it might be too late. Without treatment, half of all babies born with HIV will die before their second birthday.

“One in ten children in Lesotho does not survive to see his/her fifth birthday, most as a result of AIDS and preventable causes like pneumonia and diarrhea, exacerbated by malnutrition” said Ms. Veneman, “Facts for Life can help bridge the information gap that contributes to the needless death of millions of young children.”

The publication also contains a new chapter on child protection, which provides information on keeping children safe from violent and harmful behaviours and practices.

“Girls and boys must be protected from violence and abuse,” said the Executive Director. “Protecting children so that they can grow up in safe environments and reach their full potential can help break the cycle of poverty.”

A version of this story was first published at unicef.org

Malekena George heads home from the Pilot Health Clinic in Lesotho’s Berea district after her first antenatal check-up
Credit: © UNICEF Lesotho/2010

Malekena George, from Lesotho’s Berea district, is eight months pregnant, living with HIV, and exhausted from the five-hour trek she endured to get to the Pilot Health Clinic, for her first antenatal check-up. But because her journey to the clinic was so difficult, this visit may also be her last.

Ms. George's first child died at 13 months, and the Lesotho Ministry of Health is working to ensure that her second baby is not born with HIV.

In 2007, the Government, with help from UNICEF and other partners, initiated a massive effort to improve the country's Prevention of Mother-to-Child HIV Transmission (PMTCT) services. To succeed, they needed to ensure that every clinic in the country could provide HIV testing and treatment.

Lesotho leads the way

Lesotho became one of the first countries in the region to allow nurses to administer antiretroviral (ARV) treatments, which greatly expanded access to these critical interventions in the remote areas of the country where fewer doctors are available.

Malekena George is given her new ‘Mother to Baby Pack’ at the Pilot Health Clinic. The pack includes ARV drugs and antibiotics
Credit: © UNICEF Lesotho/2010

But despite such efforts, major challenges remain, including the fact that many women, like Ms. George, are likely to make only one clinic visit.

This is a typical problem for many health systems in Africa. Though ARV drugs substantially increase the chances that a baby is born free of the virus, providing HIV-positive mothers with the treatment is not easy, especially in remote areas. The combination of distance, lack of transport and poverty prevents many women from making regular antenatal care visits. Such factors also lead many women to drop out of the PMTCT programmes, and to deliver their babies at home without the presence of trained medical professionals.

In a country such as Lesotho, where one in four people is living with HIV, that one antenatal visit has become all the more critical.

Keeping mother and child healthy

Innovative prevention methods are making a huge difference. The Lesotho Government has designed a minimum package for expectant mothers like Ms. George that includes the most effective ARV drugs and antibiotics needed to keep them, and their children, healthy. When they leave the clinic, women are also provided with clear instructions on what medicines they need to take – and when – and what medicines they need to give to their babies after birth.

In an effort to expand this public health innovation ever further, UNICEF and WHO have created a colour-coded take-home box that will be rolled out to five countries in eastern and southern Africa, Lesotho included, by July. Instead of the nurses having to pack all the medicines in small pill bags, this new 'Mother to Baby Pack' clearly separates the ARV drugs and the antibiotics according to when they need to be taken.

"We had to take advantage of the first antenatal visit," said UNICEF HIV and Maternal Health Expert Blandinah Motaung. "In case a woman delivers at home, she will have that package with her."

A dramatic drop in infections

With the new regimen of ARV treatments, and the efforts to facilitate women taking these medicines at home, health experts expect the number of babies born with HIV in Lesotho to drop dramatically.

"The expectation is that with better adherence to treatment and more focus on helping mothers to exclusively breastfeed for six months, we can further reduce the transmission rate to less than five per cent," said Ms. Motaung.

Take home medicine

After her check-up, Ms. George listened carefully to Marethabile Lelia, the clinic nurse, give instructions on the medicines that she would be carrying home. The mother-to-mother counsellor reiterated the importance of sticking to the treatment.

Although Ms. George has another appointment scheduled at the clinic, Ms. Lelia doesn't expect to see her until she returns with a six-week-old for the baby's first round of immunizations and first HIV test - children are again tested at 12, and then 18 months

As she prepared for her five-hour walk home, Ms. George clung to her medicines, understanding clearly that they represented her best hope of ensuring that her baby would escape HIV infection and grow up healthy

Lesotho has the third highest adult HIV prevalence in the world at 23.2%. There are an estimated 270,273 people living with HIV in Lesotho as of end 2007 of which 258,472 are adults and 11.801 children. At the end of 2007, an estimated 3,966 pregnant women with HIV received anti-retroviral treatment to prevent mother to child transmission (PMTCT) of HIV. The coverage of PMTCT programmes has increased from an estimated 5% in 2005 to 42% in the first quarter 2009

South Africa’s Deputy President Kgalema Motlanthe addresses opening of IAS 2009
Credit: International AIDS Society / Simon Deiner / SDR Photo

The Deputy President of South Africa, Kgalema Motlanthe has pledged to strengthen work on eliminating mother to child transmission of HIV.

His declaration came during his welcoming address at the opening session of the 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention, taking place in Cape Town, South Africa from 19-22 July.

The Deputy President said that the importance of eliminating mother to child transmission of HIV was reinforced to him during his meeting with the Executive Director of UNAIDS, Michel Sidibé with whom he had met just three days earlier in Pretoria.

The two men met whilst Mr Sidibé was on an official visit to South Africa to highlight some of the key priority areas he urged South Africa to focus on in the coming years.

(from left) Mr Michel Sidibé, UNAIDS Executive Director; Dr Aaron Motsoaledi, Minister of Health of the Republic of South Africa and Mr Kgalema Motlanthe, Deputy President of the Republic of South Africa and Chair of the South African National AIDS Council after a meeting in Pretoria, South Africa on 16 July 2009.
Credit: UNAIDS/G.Williams

The meeting took place just a day after the Executive Director had visited the paediatric ward of the Queen Elizabeth II hospital in Maseru, Lesotho where staff were caring for children born with HIV. An experience which Sidibé described as “a sad realisation of how much still needs to be done to prevent mothers living with HIV from transmitting the virus to their babies”.

The Deputy President said that during the meeting they had agreed that South Africa must ensure that it dramatically decreases the number of infants that are infected so that it can have a generation free from HIV.

Mr Sidibe has championed preventing mother to child transmission of HIV as one of UNAIDS nine priority areas which have been recently defined in a “Joint Action for results: UNAIDS Outcome Framework”