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The health and social work subsector was estimated to have registered a high growth rate of 8.6 percent in 2016 compared with growth of 8.9 percent in 2015. Its robust performance was driven by health initiatives funded by the Millennium Challenge Corporation (MCC), resulting in improved access to health facilities for rural populations in remote areas. Projects focused on building and renovating clinics and bringing health facilities closer to the rural areas.

 

The Queen ‘Mamohato Memorial Hospital, which was opened in 2011, currently serves as both a national referral and district hospital, while the old Queen Elizabeth II Hospital has been partially reopened for limited health services. The capacity of satellite filter clinics in Maseru and surrounding areas has been dramatically improved in recent years, effectively reducing pressure on the national referral hospital.

 

Despite improving infrastructure, the lack of adequately qualified healthcare professionals continues to challenge the sector, exacerbated by Lesotho’s topography and the isolation of many rural areas where the majority of the population resides. This represents a significant access barrier to both healthcare personnel and patients. Retaining health workers in the remote parts of the country is also problematic, and primary healthcare services in these locations experience chronic shortages of medical and allied health professionals.

Health sector investment

Lesotho’s Government allocates over 10 percent of public resources to the health sector. This is one of the highest contributions in Sub-Saharan Africa, although still below the Abuja agreement of 14 percent. The investment equates to 9 percent of Gross Domestic Product (GDP), with a per capita expenditure of US $54 which is well above the World Health Organisation (WHO) recommended minimum of US $34. However, Lesotho’s health outcomes have not been commensurate with the resource input.

 

The proposed 2017/18 budget amounted to M2.5 billion. Lesotho is implementing the Test and Treat guidelines which recommend that Anti-Retroviral Treatment (ART) be administered to all persons who test positive for HIV as soon as possible after diagnosis, irrespective of their clinical stage. The MoH is also implementing the Lesotho Population Based HIV Impact Assessment nationwide to generate data on HIV and AIDS across the entire population. The survey will enable better understanding of the impact of HIV in the country.

Beyond HIV and AIDS, the cancer epidemic needs to be addressed urgently. The cost of cancer referrals to the Republic of South Africa for radiotherapy is skyrocketing. To promote cost-cutting and the sustainability of treatment, Government is considering building a Cancer Treatment Centre (CTC) in the next fiscal year. Furthermore, the Government of Japan has donated ten dialysis machines, and a dialysis centre has been established at Motebang Hospital.

 

With regard to Social Development, the National Social Protection Strategy identifies the Child Grant Programme (CGP) as a flagship initiative to alleviate poverty and increase investment in the health and education of orphans and vulnerable children. Consequently, the grant programme was targeted to increase coverage from 26 000 households to 38 000 across 36 community councils in 2017/18.

In 2016 Lesotho adopted, and is presently implementing, the WHO’s ‘Test and Treat’ guidelines on treating every person testing positive for HIV, regardless of their CD4 count.

COUNTRY ANALYSIS: LESOTHO

Published in September 2017, the final draft of the United Nation’s Lesotho Country Analysis Report is based on a desk review of literature and consultation with government ministries, departments and agencies. United Nations (UN) agencies working in Lesotho also prepared Issues Papers on thematic areas (environment, climate change and resilience; gender equality and women’s empowerment; governance; health, nutrition, HIV and AIDS, poverty, social protection, and youth) that provided data and information for the report.

 

According to the analysis, the root causes of Lesotho’s health system challenges and limited access to health services include the following:

Limited accountability, including a lack of supervision, incomplete documentation and data, and only partial implementation of policies

Inadequate skills and capacities of human resources

Weak supply chain management

Socio-cultural factors such as limited community empowerment and access to services

 

The report provides a baseline to envision and prioritise issues for the new United Nations Development Assistance Framework (UNDAF 2019-2023) for Lesotho. There are significant developmental challenges that need to be tackled if the country is to address the UN’s 2030 Agenda for Sustainable Development, African Union (AU) Agenda 2063, and achieve the country’s Vision 2020. At present, development and social progress indicators are below the expected targets for a low middle-income country, and the analysis indicates that Lesotho must strategically and comprehensively plan to deal with core development needs and priorities from the 2030 Agenda’s perspective but based on the country’s context and past performance.

Strengthening health sector quality and access

According to the country analysis report, the current high investment in health has not translated into improved health outcomes for the population. The UN recommends putting in place an all-inclusive, consultative process to finalise Lesotho’s five-year Health Sector Strategic Plan and Health Policy, in which the UN Sustainable Development Goals (SDGs) have been mainstreamed. These strategic health documents will facilitate a coordinated joint stakeholder implementation and review process. Further analytical work to determine and address the underlying causes of ill health and inefficiencies in the sector need to be carried out with support from UN, health stakeholders and donors, with the government leading the process. This should include the evaluation of previous health sector programmes, including the Health Sector Reform Project Phase 2 supported by the World Bank.

 

High maternal and child mortality and HIV-related deaths are partly due to the poor quality of service delivery. Continued implementation of the comprehensive Human Resources Development and Strategic Plan (2005-2025) to recruit and retain healthcare professionals will strengthen human resource for health structures. Government should, at both national and local levels, work with development partners and civil society organisations (CSOs) to reduce waste and inefficiency in the procurement and supply chain system to ensure that supplies and equipment are available in sufficient quantities and are of a suitable quality.

 

Completion of the current, and development of a new, Health Management Information System (HMIS) will streamline the existing multiple data systems sources and ensure the availability of accessible, uniform and validated real-time data for evidence-informed intervention. The establishment of a robust surveillance system and contingency plans will help in preparing for, as well as managing and responding to, health emergencies. Finally, strengthening the leadership, governance and stewardship role of the MoH should lead to better management and accountability for enhanced results.

HEALTH PROFILE

The MoH adopted the Primary Health Care (PHC) strategy in 1978. However, health outcomes remain below expectations. High rates of communicable diseases and HIV/AIDS exert a great deal of pressure on health infrastructure and resources. At the same time, the health sector in Lesotho has suffered from high attrition with regard to its health professionals in recent years, in spite of efforts to reform the health sector within the context of the National Health Plan. The World Bank estimates that one-third of Lesotho-born physicians have emigrated.

 

Lesotho has an elevated burden of AIDS-related deaths as well as high mortality due to non-communicable diseases, including cardiovascular and chronic respiratory diseases, diabetes, cancer and road traffic accidents. The vulnerable and socially disadvantaged are more likely to die sooner than people of a higher socioeconomic class due to their exposure to hunger, harmful products (such as tobacco or unhealthy food), and limited access to health services.

 

Fertility and contraception

The total fertility rate (TFR) was recorded as being 3.3 in the 2014 Lesotho Demographic and Health Survey (LDHS). This has not changed since the 2009 LHDS, but is slightly lower than the rate of 3.5 reported in the 2004 survey. Fertility is notably higher among rural women than their urban counterparts, with the former group giving birth to nearly two more children during their reproductive years than urban women (3.9 and 2.3, respectively). This tallies with the finding that educated women from wealthy backgrounds are more likely to use modern contraception than less educated women from poorer homes. Teenage pregnancy in Lesotho has remained unacceptably high for the past ten years, with estimates of 20 percent in 2004 and 19 percent in 2014. These numbers are even higher among adolescent girls in rural areas.

 

As regards the contraceptive prevalence rate (CPR), a comparison of results from the last three LDHS reports reveals that the CPR among married women in Lesotho has steadily increased: from 37 percent in 2004 to 47 percent in 2009 and 60 percent in 2014. Similarly, the CPR among sexually active unmarried women has risen from 48 percent in 2004 to 58 percent in 2009 and 73 percent in 2014. Among married women, the most popular methods are injectables (used by 24 percent), male condoms (used by 17 percent), and the pill (used by 14 percent), while among sexually active unmarried women the most commonly used method is the male condom (45 percent). Furthermore, the survey reveals that 18 percent of currently married women have an unmet need for family planning services, with this figure rising to 20 percent among unmarried sexually active women.

Maternal health

Proper care during pregnancy and delivery is important for the health of both mother and baby. The 2014 LDHS results show that 95 percent of women who gave birth in the five years preceding the survey received antenatal care (ANC) from a skilled provider at least once. A little less than three-quarters of women (74 percent) had four or more ANC visits. The percentage of women receiving ANC from a skilled provider has increased slightly from 2004 (90 percent) and 2009 (92 percent). In addition, 78 percent of women reported delivery by a skilled provider, and 77 percent of births took place in a health facility – an increase from 59 percent in 2009. Home deliveries are still common in rural areas and among less educated and poor women.

In Lesotho, family planning is part of the Sexual and Reproductive Health Programme of the Ministry of Health, and an important issue in the National Strategic Development Plan.

Despite these advances, Lesotho’s maternal mortality rates are still unacceptably high at 1 024 deaths per 100 000 live births (2014), which is only slightly lower than the rate of 1 155 in 2009. This is because important healthcare services during pregnancy, childbirth and after delivery remain limited for the poor, especially those living in remote communities.

 

Prompt postnatal care (PNC) for both the mother and the child is important to treat any complications arising from the delivery, as well as to provide the mother with important information on how to care for herself and her child. A large proportion of maternal and neonatal deaths occur in the first 48 hours after delivery. However, only 62 percent of women and 18 percent of newborns receive the recommended postnatal health checks within two days of delivery. First-time mothers are the most at risk, with sepsis, abortion and hypertensive disorders among the major causes of death. The WHO estimates that some 13 percent of maternal deaths in 2015 were indirectly AIDS-related.

 

Child health and nutrition

The impact of chronic food insufficiency and hunger is grave and a major concern to the Government, the UN and NGOs. For example, one-third of children under 5 years of age are stunted, 3 percent suffer from acute malnutrition (wasting), and 10 percent are underweight. Only 11 percent of infants 6-23 months are covered by the minimum accepted dietary standards and more than half of infants 6-23 months are anaemic. More than 27 percent of women and 14 percent of men aged 15-49 are anaemic. The highest levels of chronic malnutrition prevalence is in mountains (42 percent of residents), followed by foothills (41 percent) and the Senqu River Valley (34 percent).

 

While malnutrition remains one of the most serious long-term problems facing the country, Lesotho has nonetheless seen marked improvements in stunting levels among children under the age of five, which has been reduced to 33 percent from 39 percent in 2009. Factors that have contributed to this positive trend include the provision of blanket supplementary feeding of 24 028 beneficiaries (children 6-23 months and pregnant and lactating women) and accelerated support for families and structures at community level to adopt optimal nutrition practices.

 

Lesotho has established a schedule for the administration of all basic childhood vaccines, including BCG vaccination against TB, the polio vaccine, pentavalent vaccine and measles vaccine. Since late 2008, DPT vaccine (to prevent diphtheria, pertussis and tetanus) has not been given to infants in Lesotho as a stand-alone vaccine. Instead, it has been combined with other antigens that protect against hepatitis B and Haemophilus influenzae type b. This vaccine (DPT-HepB-Hib) is known as the pentavalent vaccine. In addition, the MoH has successfully switched from trivalent Oral Polio Vaccine (tOPV) to bivalent Oral Polio Vaccine (bOPV) for routine vaccination and campaign immunisation activities.

 

According to the 2014 LDHS, among all children born in the five years preceding the survey, 68 percent received all basic vaccinations, with coverage having increased modestly since the 2009 LDHS estimate (62 percent). In total, 98 percent of children have received BCG, 98 percent the first dose of pentavalent, and 96 percent have received polio 1. Some 85 percent and 76 percent of children have received the third dose of the required three doses of the pentavalent and polio vaccines, respectively. Coverage of vaccination against measles is 90 percent. Only 1 percent of children in Lesotho have not received any vaccinations, which compares favourably to the 2009 LDHS in which 3 percent of children were reported to have not received any vaccinations.

 

The Lesotho Vulnerability Assessment Committee Report of July 2017 appraised the estimated coverage for children under five years of age in respect of vaccination, deworming and Vitamin A supplementation. The findings were as follows:

Measles-rubella vaccination coverage was recorded at more than 70 percent in all ten districts, while three out of ten districts had above 90 percent coverage (thus achieving ‘herd immunity’).

Vitamin A supplementation coverage is above 80 percent in seven districts and below 50 percent in one district (Mokhotlong). Children with vitamin A deficiency are more likely to die of measles infection.

Deworming coverage is above 50 percent in nine out of ten districts and only 20 percent in Mokhotlong. Importantly, deworming is helpful in preventing micronutrient deficiencies.

The 2014 LDHS documents a pattern of decreasing under-five mortality during the 15 years prior to the survey. While there was little change in mortality rates between the 2004 and 2009 surveys, the changes between the 2009 and 2014 surveys are striking, with the under-five mortality rate decreasing from 117 to 85 deaths per 1 000 live births. This is primarily due to a substantial decrease in infant mortality, which fell from 91 deaths per 1 000 live births to 59 deaths per
1 000 live births. Furthermore, Lesotho’s neonatal mortality rate has dropped steadily in the past decade, and now stands at 32.7 per 1 000 live births (WHO, 2015).

 

Tuberculosis (TB)

Lesotho has the second highest TB incidence in the world (788/100 000) and a low TB case detection rate of 49 percent. The treatment success rate has stagnated at approximately 70 percent for new and relapsed cases, with very high TB-related mortality of 15 percent. Late diagnosis of TB remains a challenge, contributing to high morbidity and mortality. In addition, the diagnosis and management of childhood TB remains a significant challenge, and drug resistant TB is increasing.

Lesotho has significantly reduced its child mortality rates – an indicator of a nation’s level of development – owing to improvements in child nutrition and increased immunisation against measles.

According to the Drug Resistance Survey conducted in 2013/14, the national prevalence of MDR-TB was 3.8 percent, including 3.2 percent among new TB cases and 6.9 percent among previously treated cases. The gap between notification and estimated incidence has persisted, indicating missed TB notifications. Lesotho is observing declining TB notification trends despite high WHO estimates.

HEALTH PROGRAMMES

A wide variety of development partners and donors support the Government of Lesotho in the health sector, with a large proportion of technical and financial support coming from the WHO. The Health Development Partners Forum, co-chaired by the WHO and the US President’s Emergency Plan for AIDS Relief (PEPFAR), facilitates coordination of health sector support in the country from the partners’ side.

 

Strategic priorities and focus areas under the WHO Country Cooperation Strategic Agenda (2014-2019) for Lesotho comprise: strengthening the prevention and control of HIV/AIDS, TB and MDR-TB; strengthening family and community health, including sexual and reproductive health; enhancing the capacity for the prevention and control of major communicable and non-communicable diseases; strengthening health systems capacities and performance; and fostering health sector partnerships, advocacy and equity.

The Lesotho United Nations Development Framework and Plan (LUNDAP) is fully aligned with the country’s National Strategic Development Plan and implemented through the ‘Delivering as One’ initiative. Annual reviews of the LUNDAP are conducted jointly with Lesotho’s Government.

 

The UN has provided strategic guidance through the development of national policies, plans and technical guidelines in the areas of Adolescent Health and Integrated Management of Childhood Illnesses (IMCI), Nutrition, Sexual and Reproductive Health (SRH), Non-Communicable Diseases and Neglected Tropical Diseases (NTD). These strategic documents guide the acceleration of implementation of high impact interventions needed to improve health and reduce the vulnerability of Basotho. The United Nations Population Fund (UNFPA) partners with the Lesotho Planned Parenthood Association (LPPA) and others to make Sexual and Reproductive Health Rights (SRHR), including family planning and HIV prevention services, accessible to all Basotho.

New WHO TB guidelines serve to raise awareness of TB as the world’s top infectious disease and address contentious issues such as the isolation of contagious patients, the rights of TB patients in prison, and discriminatory policies against migrants affected by TB, among others.

The Lesotho United Nations Development Framework and Plan (LUNDAP) is fully aligned with the country’s National Strategic Development Plan and implemented through the ‘Delivering as One’ initiative. Annual reviews of the LUNDAP are conducted jointly with Lesotho’s Government.

 

The UN has provided strategic guidance through the development of national policies, plans and technical guidelines in the areas of Adolescent Health and Integrated Management of Childhood Illnesses (IMCI), Nutrition, Sexual and Reproductive Health (SRH), Non-Communicable Diseases and Neglected Tropical Diseases (NTD). These strategic documents guide the acceleration of implementation of high impact interventions needed to improve health and reduce the vulnerability of Basotho. The United Nations Population Fund (UNFPA) partners with the Lesotho Planned Parenthood Association (LPPA) and others to make Sexual and Reproductive Health Rights (SRHR), including family planning and HIV prevention services, accessible to all Basotho.

 

Cancer screening

In 2013 the Elizabeth Glaser Paediatric AIDS Foundation (EGPAF), with funding from the US Agency for International Development (USAID) and PEPFAR, helped the MoH to launch services at Lesotho’s first-ever cervical cancer screening and prevention facility, the Senkatana Centre of Excellence located in the Bots’abelo Hospital in Maseru. Senkatana now offers comprehensive gynaecological services, with an emphasis on cervical cancer screenings, diagnoses, pre-cancer treatment services, and referrals to facilities for cancer treatment. EGPAF is currently working to decentralise these services to sites throughout the country.

 

Given the delay in processing test results, most clients are screened using Visual Inspection with Acetic Acid (VIA), a cost-effective alternative whose results are immediately available. Because the centre provides a full range of services, clients are also offered breast exams, HIV testing and counselling for those who do not know their status, and screening for sexually transmitted infections (STIs). Other at-risk groups are also screened for diabetes and hypertension.

 

Human papillomavirus (HPV) infection is now a well-established cause of cervical cancer, with HPV types 16 and 18 responsible for about 70 percent of all cervical cancer cases worldwide. The immunisation of girls against HPV is viewed as the most cost effective method of managing the occurrence of cervical cancer, and Lesotho has implemented a number of vaccination campaigns in recent years.


THE HIV/AIDS PANDEMIC

HIV and AIDS is a burden to the health sector and has hampered both economic growth and social progress in Lesotho, becoming the leading cause of morbidity and mortality in the country. Lesotho exhibits the second-highest rate in HIV prevalence and incidence among those aged 15-49 years, of which almost 25 percent are infected with HIV. According to the LDHS, this is significantly greater among women (29.7 percent) than men (18.6 percent), with women aged 35-39 years old having the highest prevalence at 46 percent.

 

While still high, the incidence rate has seen a significant reduction from 2.7 percent in 2004 to 1.9 percent in 2015. One out of four new HIV infections occur among adolescent girls and young women, mainly as a result of exclusion, inter-generational sexual relationships, discrimination and gender-based violence. Lesotho has an estimated 328 000 people living with HIV, including 13 000 children.

 

Of particular concern is HIV prevalence among vulnerable and risk populations, which stands at 72 percent for sex workers, 43 percent in factory workers, 33 percent in men who have sex with men, and 31 percent among prison inmates. Prevalence is higher in urban areas than in rural; with the Mokhotlong district having the lowest rate of 17 percent and Maseru the highest at 28 percent.

Only 39 percent women and 31 percent men have a comprehensive knowledge (transmission and prevention) of HIV, with lower rates in rural women (43 percent) and men (26 percent) compared with urban women (46 percent) and men (42 percent). According to the LDHS (2014), 7 percent of women and 27 percent of men had two or more sexual partners, and among these, only 54 percent of women and 65 percent of men reported using a condom during their most recent sexual encounter.

Mobility and migration, along with gender inequality, poverty, income disparities and food insecurity, are structural factors which predispose individuals to HIV infection.

While Lesotho has a number of HIV programmes operating across the country, many people struggle to access these services due to factors such as gender, socioeconomic status and geography, encountering issues such insufficient funds to travel to health centres and a lack of drug supplies. According to the Lesotho Stigma Index Report 2014, HIV stigma and discrimination are also major barriers to accessing vital treatment, prevention and support services. While the LDHS 2014 has found that attitudes towards people living with HIV have improved slightly, such individuals are still accepted by less than 50 percent of the population.

HIV PREVENTION PROGRAMMES

The HIV and AIDS response is primarily funded by the Government of Lesotho, the Global Fund to Fight AIDS, Malaria and Tuberculosis, and the United States Government through PEPFAR. The Country Operational Plan (COP) 2017 is a continuation of the COP16 approach set in the context of the broader PEPFAR-Lesotho Strategic Framework (2015-2020).

 

Since 2004, the Elizabeth Glaser Paediatric Aids Foundation (EGPAF) has worked in partnership with Lesotho’s MoH, district health teams, health facilities and communities. EGPAF currently supports more than 220 sites in ten districts to implement a comprehensive HIV package of services, including adult and paediatric TB and TB/HIV care and treatment, integrated maternal, newborn and child health (MNCH), reproductive healthcare (including cervical cancer screening and treatment), nutrition support, community engagement, community-clinic linkages, and strategic information and evaluation. Between 2004 and 2017, EGPAF-supported programmes in Lesotho have:

Conducted over 904 000 HIV tests, resulting in the identification of 63 000 HIV-positive individuals

Provided HIV services to over 16 667 new and relapsed TB cases (since October 2014)

Started more than 178 000 individuals on ART, including more than 9 900 children up to the age of 14

Currently support 139 000 HIV-positive people on ART

Provided PMTCT services to more than 253 000 women

Trained over 3 200 medical staff to provide high-quality integrated health services

 

The ‘Fast Track’ initiative

In 2014, UNAIDS embarked on the second phase of the worldwide ‘Fast Track’ initiative that seeks to end the AIDS epidemic by 2030. Fast Track proposes rapid and massive acceleration of HIV prevention and treatment programmes with a people-centred approach. The new set of targets that need to be reached by 2020 include achieving 90-90-90:

90 percent of people living with HIV knowing their status

90 percent of people who know their HIV-positive status on treatment

90 percent of people with suppressed viral loads on treatment

 

Fast Track is based on an approach which leaves no one behind, especially populations at higher risk of acquiring HIV, such as sex workers, gay men and other men who have sex with men, transgender people and people who use drugs. Under Fast Track, these groups are supposed to receive assistance regardless of where they live or the legal status of their behaviour.

Providing Universal Services for HIV/AIDS in Lesotho (PUSH) Project

The USAID-funded PUSH project runs for five years (2016-2021) and aims to effect sustained reduction in HIV transmission, morbidity and mortality. PUSH will capitalise on gains made under the USAID-funded Comprehensive HIV/AIDS Services Expansion project by sustaining support of a comprehensive package of HIV services in three districts (74 sites) and operations research at eight additional sites in other districts. Using a district-based approach, PUSH will expand coverage of HIV care and treatment services to 80 percent of the population of people living with HIV in Maseru (by 2017), and Mohale’s Hoek and Mafeteng (by 2018), while maintaining the quality of clinical services in all three districts.

According to Lesotho’s Minister of Health, Mr Nyapane Kaya, there has been an increase in routine viral load testing from 6 232 tests in June 2016 to 14 800 in June 2017.

Strengthening the TB and AIDS Response in Lesotho (STAR-L) Project (2015- 2020)

EGPAF supports the MoH in implementing a comprehensive HIV service package in more than 46 sites in Leribe and Berea districts, and providing site-level services in 45 sites of these sites based on the PEPFAR/Government of Lesotho prioritisation strategy. The goal of STAR-L is to scale-up effective, sustainable, comprehensive HIV and TB/HIV prevention, care and treatment interventions to reduce HIV transmission, morbidity and mortality. The package of services offered in these health sites includes HIV counselling and testing, PMTCT services, adult and paediatric TB and HIV care and treatment, integrated maternal and child health services and nutrition support, health systems strengthening, community engagement, community-clinic linkages, and strategic information and evaluation.

 

HIV testing and counselling

HIV testing and counselling (HTC) services have been steadily expanding across Lesotho, particularly at a community level, with more women (84 percent) than men (66 percent) having been tested at least once for HIV and received their results. PEPFAR offers direct support to MoH sites for Provider-Initiated Testing and Counselling (PITC) services. Lesotho has implemented provider-initiated testing and counselling, which is when service providers offer HTC rather than waiting for an individual to request it.

 

A study exploring the differences in HTC services, particularly mobile clinic HTC and home-based HTC services, found that mobile clinic HIV testing was more effective at detecting new infections, while home-based HIV testing was more appropriate for testing children and people who had never had an HIV test before. This information is important for current strategies to engage more people in HIV testing, and for reaching marginalised groups.

 

Lesotho is also revising HTC guidelines in order to:

Strengthen HIV Testing Services (HTS) and identify people with HIV through the provision of quality services for individuals, couples and families

Effectively link individuals and their families to appropriate HIV treatment, care and support, as well as HIV prevention services, based upon their status

Support the scale-up of high impact interventions to reduce HIV transmission and HIV-related morbidity and mortality, with the focus on antiretroviral therapy, voluntary medical male circumcision, PMTCT, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP)

 

To meet treatment targets for the 2018 fiscal year, PEPFAR aims to identify an additional 8 522 HIV-positives individuals in high volume sites and link them to treatment. Facility-based and family tree testing will be the primary modalities for case identification.

 

Test and Treat

Lesotho was the first African country to launch the ‘Test and Treat’ strategy for HIV and HIV Testing Services (HTS) guidelines. The Government of Lesotho has wasted no time in implementing Test and Treat, which was launched in June 2016 and has subsequently been rolled out countrywide.

Guidelines had hitherto stipulated that people could only access treatment when their CD4 count was 500 and below, when they became very sick (as per WHO clinical staging), or if they belonged to selected populations (pregnant women, children and others). However, following various international research studies demonstrating that earlier use of ART is more beneficial and life-saving than delayed treatment, and the dissemination of the WHO Early Release Guidelines in September 2015, the standard policy going forward is that ART should be initiated in everyone living with HIV, regardless of their CD4 count.

 

Antiretroviral therapy

The scale-up of Anti-Retroviral therapy (ART) in Lesotho has accelerated in recent years, and currently stands at 57 percent of all people living with HIV against 42 percent in 2015. However, this is far below the 80 percent global coverage target. ART coverage in children now stands at 64 percent in the scale-up districts, which is a testament to the impact of the Accelerating Childhood Treatment (ACT) initiative. Equally important are the new service delivery models that have been implemented, which require fewer lab tests, less frequent clinic visits, multi-month prescriptions, and same day treatment initiation. These demonstrate that expanded treatment coverage is possible within the existing health system, as are improved retention rates among patients.

PEPFAR’s investments during COP17 are intended to expand ART coverage in five districts to 90 percent during the 2018 fiscal year in order to achieve saturation across all age groups and sexes. PEPFAR also intends expanding geographically to 18 high-volume sites within the five sustained districts, thus maximising the efficiency of investments and expanding the capacity of the national programme.

Lesotho is making progress in the fight against HIV/AIDS, with more than 140 000 people living with HIV currently on ART and 90 percent of 175 497 viral load tests conducted being virally suppressed.

Voluntary medical male circumcision

Evidence from international research, as well as the findings of the MoH situational analysis, indicates that male circumcision reduces transmission from a woman to a man by 60 percent. Implementation of Lesotho’s voluntary medical male circumcision (VMMC) programme began in 2012. PEPFAR Lesotho is currently working with the MoH to scale up VMMC coverage to 80 percent among males aged 15–29 in five districts with a high unmet need for circumcision and HIV disease burden.

 

In May 2015 a new VMMC project was launched at Scott Hospital in Morija, sponsored by PEPFAR, administered by USAID, and implemented by Jhpiego, an international, non-profit health organisation affiliated with the Johns Hopkins University. This is part of more than US $225 million in bilateral support from the US Government to help Lesotho combat the HIV/AIDS epidemic.

 

In the 2018 fiscal year, PEPFAR aims to provide surgical direct service delivery to circumcise 50 182 men (41 400 aged 15-29 and 8 782 aged 10-14). This represents 85 percent saturation in the age pivot 15-29 years in the five priority districts of Berea, Maseru, Leribe, Mafeteng and Mohale’s Hoek. Technical assistance will be provided for the integration of early infant male circumcision in maternal and neonatal child health programmes in the saturated districts for sustainability.

 

Demand creation activities in scale-up districts will include forging collaborations between medical and traditional male circumcision practices due to the high prevalence (32-65 percent) and cultural significance of traditional circumcision. The MoH, with the support of Jhpiego, has conducted mapping of traditional circumcisers in the supported districts as a first step to facilitate further engagement. Jhpiego will provide medical circumcision to traditional initiates at health facilities prior to the rite of passage ceremonies, and the Ministry of Education and Training has given Jhpiego permission to implement demand creation activities for VMMC in learning institutions.

 

Additionally, JHPIEGO also sub-grants to two CSOs – LENASO and the Lesotho Planned Parenthood Association – for a total of US $273 000 a year. Anticipated challenges to achieving the targets include transport logistics for hard-to-reach areas, overcoming the traditional belief that circumcision is better performed during winter months when healing is thought to be quicker, providing medical circumcision to men with prior ‘partial’ traditional circumcision, and refocusing demand to encourage a larger percentage of 15 -29 year olds to access VMMC services.

TB/HIV co-infection

The HIV prevalence among TB patients is estimated at 72 percent and the ART uptake is 86 percent among the notified TB HIV-positive patients. High risk groups for TB in Lesotho include children, pregnant women attending ANC, people living with HIV/AIDS, health workers, mine workers, the military, inmates and factory workers (who are also predominately migrants).

 

The five PEPFAR scale-up districts account for 80 percent of the notified TB cases. Current priorities aim to:

Achieve or maintain 100 percent HIV testing rates among all TB cases and patients with presumptive TB

Provide universal ART for all people with TB diagnosed with HIV

Ensure timely TB diagnosis and TB treatment completion to ensure viral suppression

Scale-up TB preventive therapy (TPT) for all people living with HIV without active TB disease and implementation of TB infection prevention and control interventions

Support integrated and effective delivery of TB/HIV services at national, district and site level

 

Based on the key COP 17 priorities, funding for TB/HIV initiatives covers a variety of activities. Key amongst these is the scaling-up of GeneXpert MTB/RIF22 and improving the early diagnosis of TB among people living with HIV to close the gap between current estimated TB incidence and notification rates. TB case detection is being intensified through the use of mobile laboratories loaded with Xpert MTB/RIF focusing on high risk groups within the country, while support is provided for TB/HIV services at border points of care, and the integration of TB/HIV care and treatment services in PEPFAR scale-up sites. TB preventive therapy is also being intensified for all people living with HIV without active TB disease.

 

Pre-Exposure Prophylaxis (PrEP)

Lesotho has an estimated 13 000 children and 15 776 adolescents living with HIV, as well as 73 000 children orphaned by HIV (UNAIDS, 2016). Though the HIV epidemic is generalised, incidence is disproportionately highest among adolescent girls and young women (AGYW), female sex workers (FSW), men who have sex with men (MSM), multiple concurrent partners, and those reporting sexually transmitted infections. The revised national guidelines on the use of ART for HIV prevention and treatment (2016) recommend use of oral TDF/3TC for HIV-negative individuals at significant risk of acquiring HIV infection.

 

The current initiative being implemented by PEPFAR and the Lesotho Government is to extend PrEP services to targeted groups in the priority districts using hybrid service delivery models. In the 2018 fiscal year, PEPFAR aims to provide PrEP services to 23 721 beneficiaries (13 945 girls aged 18-24, 8 256 sero-discordant couples, 950 MSM and 570 FSW). PEPFAR is providing focused technical assistance on selected indicators to ensure quality of services and data for decision-making and ensure all the necessary systems are in place prior to rolling out PrEP.

DREAMS

PEPFAR’s DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe) initiative aims to reduce HIV infections among adolescent girls and young women in ten Sub-Saharan African countries. For COP17, the implementation of DREAMS continued in the districts of Maseru and Berea, and will expand to other community councils in these two districts to ensure full coverage and saturation. There is a greater emphasis on bio-medical interventions for AGYWs as well as increasing their linkages to testing services, and enrolment and retention into care and treatment for those needing it.

 

Services include school-based HIV risk avoidance and violence prevention, community mobilisation and norms change activities, condom promotion and distribution programming, post-violence care, testing and counselling services, contraceptive mix options and PrEP. DREAMS is positioned to implement aggressive prevention for 79 510 young women and gender-based violence prevention for 2 746.

Prevention of mother-to-child transmission (PMTCT)

The burden of HIV disease among pregnant women in Lesotho is among the highest globally, with a 27 percent HIV prevalence rate among women attending ANC. The National PMTCT Strategy is to eliminate new paediatric HIV infections and improve maternal, newborn and child health and survival in the context of HIV. Routine viral load monitoring for all pregnant and lactating women and children was adopted as a standard of care in 2016.

The quality of PMTCT service delivery has continued to maintain high uptake of services within health facilities, with over 95 percent of pregnant women knowing their HIV status at their first ANC visit and 93 percent of the identified HIV-positive pregnant women receiving ARVs to prevent mother-to-child transmission (MTCT) of HIV. The MTCT rate among HIV-exposed infants less than two months of age is 1.6 percent.

The MoH has introduced a sample tracking tool for Early Infant Diagnosis, which has resulted in an improved turnaround time for test results, allowing HIV positive infants to be initiated on ART as soon as possible.

UNITAID (2015-2019)

The UNITAID project in Lesotho aims to increase the number of HIV-positive infants whose HIV status is known and facilitate early ART initiation for these children. To accomplish this, EGPAF-Lesotho is working with in-country partners and the Lesotho MoH to strategically place new-to-market point-of-care early infant HIV diagnosis (EID) platforms within health facilities. Through UNITAID funding, Lesotho will by the end of 2018 have 29 EID testing sites, mostly ar ‘hubs’ or high-volume sites, receiving samples from an additional 160 ‘spoke’ sites. The project aims to achieve reduction in turnaround time between blood sample collection and results receipt by caregiver from the current 30-60 days to zero days at hub sites and seven days at spoke sites. It also aims to reduce the number of days from receipt of results by a caregiver to ART initiation among HIV-infected infants to less than 14 days, and ensure 648 infants (90 percent of identified infants) are receiving treatment by project end.

HEALTHCARE INFRASTRUCTURE

The health system in Lesotho consists of a network of hospital, filter clinics, health centres, health posts, outreach services and mobile clinics. The MoH, together with its implementing partners the Christian Health Organisation of Lesotho (CHAL), Lesotho Red Cross Society (LRCS) and the private sector, work to deliver equitable health services to all Basotho.

Assistance is also received from multiple development organisations. The Health Sector Programme of the Millennium Challenge Account (MCA) has been an important source of funding for Lesotho’s healthcare facilities. This has seen the rehabilitation and expansion of 138 health centres across the country, expansion of 14 hospital outpatient departments, construction of a new laboratory and a new blood transfusion service centre, as well as dormitories for students and teachers at the National Health Training Centre (NHTC). The new National Laboratory and Blood Transfusion Centre based in Botšabelo, Maseru, aims to improve laboratory and diagnostic services to support the management of HIV/AIDS and nationwide TB programmes, as well as assure adequate and safe blood supplies for HIV/AIDS patients.

 

Opened in October 2011, the Queen ‘Mamohato Memorial Hospital in Maseru is a state-of-the-art referral hospital named after the late Queen ‘Mamohato Bereng Seeiso. Accommodating 425 patients – 35 private and 390 in the general ward – and some 700 employees, the ultra-modern hospital was built through a Public-Private Partnership agreement. It replaces the Queen Elizabeth II Hospital, which was built more than half a century ago. Serving 20 000 inpatients and 310 000 outpatients a year, Queen ‘Mamohato Memorial delivers significantly more services and services of a higher quality than its predecessor, offering magnetic resonance imaging, laparoscopy procedures, neurosurgery, pathology services, intensive-care facilities, and 24-hour obstetrics at filter clinics. An additional dental laboratory has also been established here.

 

The Molecular Diagnostic Laboratory at Motebang Hospital in Leribe has been refurbished at a cost of M2.3 million. This will enable it to meet the rapid expansion in viral load testing, with the laboratory to process 280 specimens in an eight-hour shift, which amounts to 70 000 tests per year. This refurbished facility negates the need for specimens to be taken to the national laboratory, and thus reduces the time taken for results to be available from four months to a week.

 

Scott Hospital, the birth place of the King Letsie III, is an institution of the Lesotho Evangelical Church in Southern Africa (LECSA) and was founded nearly 80 years ago. The Scott Hospital Improvement Project (SHIP) was officially launched by His Majesty King Letsie III on
4 May 2016. Besides renovation work, SHIP hopes to build a new children’s hospital, with the aim of making it into the nation’s premier facility for paediatric healthcare.

 

Other phases of SHIP include constructing a new maternity wing and major renovation work and upgrading of both Scott Hospital and the Scott Hospital School of Nursing. The scope of SHIP is large, with an estimated cost of at least
US $10 million. Work will be carried out in phases as funding is secured. The first step of the project is renovation of the Labour Ward, which is being funded through a generous donation of
US $75 000 from the Republic of Turkey.

 

Lesotho’s other top hospitals include Maseru Private Hospital in Thetsane, and Wilies Hospital in Khubetsoana, Maseru. Additional health facilities in the Maseru area include Mohlomi Hospital for the Mentally Ill; Baylor College of Excellence, which caters for children with HIV/AIDS; Senkatana for the provision of ART to adults; and the NHTC, which trains nursing professionals and more recently medical students.

 

Lesotho’s only military health institution, Makoanyane Military Hospital (MMH) was established in 1988 by the Lesotho Defence Force to provide health services for those in the military as well as their family members. Infrastructure development has seen the creation of various medical and non-medical departments, such as physiotherapy, laboratory, maternity ward extension and expansion of medical stores, as well as the creation of a Wellness Centre containing a TB clinic, hypertensive and diabetes clinic, mother and child health and family planning clinic and HIV/AIDS clinic.

 

Vision Clinic Laboratory was established in November 2013 with the objective of cutting the cost of importing lenses by manufacturing high quality lenses in Lesotho. Vision Clinic supplies optometry practices in Lesotho and abroad. The Lab offers surfacing and edging of lenses using advanced technological machines (satisloh toromatic-cnc-computer). Vision Clinic supplies different lens types, from single vision to progressive lenses, including coating as well as fitting of high refractive index lenses.