Country Spotlight: Lesotho

Country Overview

Nearly 25% of the population of Lesotho is living with HIV and HIV/ AIDS is the country’s leading cause of death. Lesotho is suffering from a double epidemic of both HIV and tuberculosis (TB) – it is the second-worst hit country by both diseases in the world. Women are disproportionally affected by the HIV/AIDS epidemic, with prevalence exceeding those of men in almost every age group under 40 years.

Our Work in Lesotho

The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), which seeks to end pediatric HIV/ AIDS and enhance maternal, neonatal and child health (MNCH) through implementation of HIV prevention, care and treatment programs, advocacy, and research, began collaborating with Lesotho’s Ministry of Health in 2004 to eliminate the epidemic.

Through leadership from the Government of Lesotho and support from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), Lesotho significantly scaled up HIV service access. EGPAF, the leading implementing partner supporting this rapid scale up, has used a district-focused approach to deliver high-quality HIV services. EGPAF provides the Ministry of Health, district health teams and health facilities with support through a refined and tailored technical assistance model. EGPAF currently supports more than 220 sites in 10 districts to implement a comprehensive HIV package of services.  This package includes support for provision of HIV counseling and testing, prevention of mother-to-child transmission of HIV (PMTCT) services, adult and pediatric HIV care and treatment, adult and pediatric TB and TB/HIV care and treatment, integrated MNCH and HIV services, reproductive health care (including cervical cancer screening and treatment), nutrition support, community engagement, community-clinic linkages, and strategic information and evaluation. As a key partner to the Ministry of Health, EGPAF also actively participates in six national HIV-related technical working groups and advisory committees to develop informed policies supporting all persons affected by HIV. EGPAF-Lesotho is also dedicated to advancing basic and operations research to strengthen the effectiveness of the global HIV and AIDS response.

Comprehensive HIV/AIDS Service Expansion Project: The Chase Project (USAID/PEPFAR: 2015 to 2016)

EGPAF, in collaboration with Baylor College of Medicine Children’s Foundation-Lesotho and the Lesotho Network of AIDS Service Organizations, is supporting Lesotho’s Ministry of Health and district health teams to provide the comprehensive HIV service package in more than 125 sites in Maseru, Mafeteng, Mohkotlong, Thaba Tseka, Butha Buthe, and Mohale’s Hoek districts. The package of services includes HIV counseling and testing, PMTCT services, adult and pediatric TB and TB/HIV care and treatment, adult and pediatric HIV care and treatment, integrated MNCH and HIV services, reproductive health (including cervical cancer screening and prevention) services, nutrition support, health systems strengthening, community engagement, community-clinic linkages, and strategic information and evaluation. The overall goal of CHASE is to sustainably reduce HIV transmission and related morbidity and mortality by strengthening coverage of integrated and comprehensive HIV prevention, care, and treatment services in order to reverse Lesotho’s HIV epidemic by the end of 2020. CHASE is made possible by PEPFAR through the United States Agency for International Development (USAID) funding.

Supporting HIV and TB Response in the Kingdom of Lesotho Through District-Based Comphrensive HIV Prevention, Care and, Treatment Programs and Health Systems Strengthening: The Start-L Project (CDC/PEPFAR: 2015-2020)

EGPAF, in partnership with Baylor College of Medicine Children’s Foundation-Lesotho and the Lesotho Network of AIDS Service Organizations, supports Lesotho’s Ministry of Health to implement a comprehensive HIV service package in more than 75 sites in Leribe, Berea, Qacha’s Nek, and Quthing districts. 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 under STAR-L includes HIV counseling and testing, PMTCT services, adult and pediatric TB care, adult and pediatric HIV care and treatment, integrated MNCH services and nutrition support, health systems strengthening, community engagement, community-clinic linkages, and SI&E. STAR-L is made possible by PEPFAR through the U.S. Centers for Disease Control and Prevention (CDC) funding.

Scaling up Provider-Initiated HIV Counseling and Testing (PITC) of Children by Integrating PITC Into Under-5 (U5) Services in Two Districts of Lesotho (UNICEF: 2014-2015)

EGPAF is systematically integrating PITC for infants and children in the U5 setting at 17 sites across two districts of Lesotho to increase the percentage of eligible children provided with HIV testing and counseling and the percentage of eligible children initiated on antiretroviral therapy.



Key Projects in Lesotho

Strengthening Clinical Services (SCS) Project (USAID/PEPFAR: 2010 to 2015)

The Strengthening Clinical Services (SCS) Project is made possible through support from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) and the U.S. Agency for International Development (USAID). Under SCS, EGPAF supports Lesotho's MOH to provide a comprehensive HIV service package in more than 140 sites. In 2011, Lesotho achieved the first of its primary SCS goals: scaling up PMTCT services to all public and private facilities nationwide. EGPAF is working to establish universal access to adult and pediatric HIV/AIDS care services and 90% facility coverage for adult and pediatric ART services by 2015.

As the MOH's key implementing partner for HIV/AIDS clinical services in Lesotho, EGPAF also plays a strong technical assistance role, nationally. EGPAF participates in all relevant national technical working groups and technical advisory committees, and serves as co-lead of the PMTCT national technical working group. EGPAF supports the MOH by leading and participating in the drafting and revision of national guidelines, training materials, and policies.

EGPAF has supported the MOH to successfully integrate HIV/AIDS services with maternal, neonatal, and child health services in health facilities. EGPAF also supported the creation of a national cervical cancer screening program at the Senkatana Center at Botshabello Hospital.

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Evaluation of the Xpert HIV-1 Qual Assay (Cepheid: 2014-2015)

This research study, conducted with medical diagnostics company Cepheid, is one of two in Lesotho. EGPAF is assisting with the field-testing of an innovative HIV test using small blood samples.

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Stepping Up Universal Access: A Multi-Sectoral Partnership Response to HIV at the Community Level (Global Fund: 2014)

EGPAF’s activities under this project aim to improve sexual and reproductive health outcomes for women across all 10 districts of Lesotho. Funded through Global Fund Round Eight, EGPAF is serving as the technical agency to the MOH. EGPAF is targeting to train 200 healthcare workers and over 500 village health workers on sexual and reproductive health, including cervical cancer screening and prevention. Cervical cancer is the leading cause of mortality for women in Lesotho. The clinical and community components of this project will complement each other towards strengthening uptake of and access to quality sexual and reproductive health services.

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Prevent the Spread of HIV/AIDS and Mitigate the Impact of HIV/AIDS among Orphans and Vulnerable Children in Lesotho Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund: 2013 to 2014)

Pivoting around Lesotho's National Strategic Plan for Elimination of MTCT and for Pediatric HIV Care and Treatment (2011 to 2016), this project aimed to prevent the spread of HIV and mitigate the impact of AIDS among orphans and vulnerable children. Funded through Single Stream of Funding (SSF) from Global Fund Rounds Seven and Nine, EGPAF served as the technical agency to the MOH. EGPAF trained more than 3,000 village health workers to strengthen community-level support for PMTCT services, coordinated MOH community activities, conducted PMTCT supervisory visits to ensure service quality, and trained district teams on data quality. EGPAF's role in revitalizing the national village health worker program and providing technical assistance on PMTCT and data quality is expected to result in increased service utilization and quality towards elimination of pediatric HIV in Lesotho.

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Integrating Adolescent Health Services into Routine Family Health Days and Exploring Barriers and Facilitators to Effective PMTCT Program Implementation (UNICEF: 2013 to 2014)

Due to the stigma attached to adolescent sexuality, there are gaps in accessing and providing quality adolescent-friendly reproductive health services (AFRHS) at health facilities. However, at the community level, there is a great potential for integrating, scaling up and sustaining AFRHS, as was discovered during EGPAF's 2012-2013 United Nations Children Fund (UNICEF)-funded project Scaling up Adolescent Health Services Through Family Health Days- an outreach activity used to reach hard-to-reach areas of Lesotho with necessary diagnostics and treatment. EGPAF, the MOH, and UNICEF collaborated again on another AFRHS project, with the objective to integrate AFRHS into routine rounds of Family Health Days. The project used the first day of each Family Health Day as a special emphasis day for AFRHS. Overall, a total of 3,462 clients were offered HIV testing and counseling and other services at Family Health Days including 1,813 adolescents (52%).  The 127 clients, who tested HIV-positive, including 28 adolescents (1.5%), were enrolled into care at nearby health facilities.

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Onsite training for Health Care Workers in Thaba Tseka District on the New National PMTCT Guidelines (Option B+) (UNICEF: 2013)

In April 2013, Lesotho’s MOH initiated a policy change to support the implementation of lifelong ART for all HIV-positive pregnant women nationwide (Option B+). To improve quality service delivery of PMTCT Option B+ in the district of Thaba Tseka, EGPAF provided onsite training to 183 healthcare workers from August-September 2013. One hundred women at these health facilities were initiated on ART during the two months after the training (with six women declining). In the two months before the training, 52 women were initiated on ART (with 18 declining) at the same health facilities.

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The Partnership for Management Development (Johnson & Johnson and PEPFAR/USAID: 2012 to 2013)

One of EGPAF-Lesotho's key health systems strengthening initiatives has been the Partnership for Management Development (PMD), a program designed by the University of Cape Town (UCT) Graduate Business School faculty for the Lesotho MOH and implemented by EGPAF. The program aimed to address an identified gap in health services and accelerate the elimination of mother-to-child transmission (MTCT) of HIV by developing the management capacity of African healthcare leaders. The PMD program was funded through a public-private partnership between PEPFAR/USAID and Johnson & Johnson. A gap analysis identified four topics for improvement: team-based leadership; facility-based deliveries; supply/drug stock-outs; and data use to support managerial approaches. More than 700 healthcare workers were trained. In one year, the percentage of HIV-positive infants decreased from 4% to 3%, and average attendance of first and fourth ANC visits increased by 7 %. Facility-based deliveries increased from 41% to 64%, and timeliness of report submission from health facilities to district level also improved.

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Operations Research of the Mother Baby Pack (UNICEF: 2012 to 2013)

The Mother-Baby Pack (MBP) is a take-home pre-packaged medicine pack to prevent mother-to-child transmission of HIV. With support from UNICEF, EGPAF conducted an evaluation of Lesotho's MBP program to determine the feasibility, acceptability, and lessons learned through use of the packs and to identify barriers or potential harms associated with their use. Results from the MBP evaluation will have significant implications for the PMTCT of HIV program in Lesotho as well as globally, as other countries consider implementation of this innovative approach for PMTCT drug distribution.

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Scaling up Adolescent Health Services Through Family Health Days (UNICEF: 2012 to 2013)

The goal of this UNICEF-funded project was to provide integrated health services and make them accessible through community outreach. EGPAF conducted family health day campaigns in two identified districts (Berea and Qacha’s Nek), with a targeted and expanded focus on adolescents. Specific objectives were to integrate adolescent reproductive health into family health day campaigns, provide HIV testing and counseling to adolescents, and identify and support adolescents living with HIV. EGPAF reached a total of 2,590 clients over a course of five days with comprehensive health services, of which 997 (38.5 percent) were adolescents.

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Lesotho Together Against HIV and AIDS Partnership (LETLAMA) (USAID/PEPFAR: 2011 to 2013)

This USAID/PEPFAR-funded project, led by Population Services International (PSI), sought to reduce HIV incidence among youth and adults by increasing the adoption of protective behaviors and supporting healthy social norms. EGPAF served as one of the project’s lead implementers of HIV clinical services programming. EGPAF collaborated with the MOH to revitalize and scale up post-exposure prophylaxis activities in all health facilities in Lesotho, and integrated HIV and sexually transmitted infection services.

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Strengthening Monitoring and Evaluation of PMTCT (UNICEF: 2011 to 2013)

With support from UNICEF, EGPAF provided targeted technical assistance to improve systems for monitoring and evaluation (M&E) of PMTCT programs in Cameroon, Lesotho, and Zambia. In Lesotho, EGPAF supported the MOH and other stakeholders by training health care staff on standard operating procedures for antenatal care and labor and delivery registers. In addition, EGPAF worked with Lesotho’s MOH to strengthen the timely and accurate transfer of PMTCT data from the districts to the central level through the use of 3G internet technology.

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Expediting Access to Antiretroviral Treatment for Infants and Young Children (ViiV Healthcare: 2010 to 2013)

This project, launched in 11 countries including Lesotho, sought to expedite access to testing, care, and ART for infants and young children. By project end, there were significant improvements in key indicators, including more HIV-exposed infants tested within eight weeks of birth; more HIV-exposed infants that tested positive receiving their results within eight weeks of testing; and more HIV-exposed infants and young children (IYC) that tested positive being initiated on ART. The first-ever training in Lesotho on psychosocial support counseling for HIV-positive children and caregivers was held and proved very successful. This project also enabled the Lesotho team to pilot and update the under-five register.

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System Development and Mentoring for Integration of Active Case-Finding for Tuberculosis (TB) and Isoniazid Preventive Therapy with PMTCT of HIV Services (PMTCT) in Lesotho (Johns Hopkins University: 2010 to 2013)

Lesotho implements active case-finding of TB by clinical symptom screening and provision of isoniazid preventive therapy (IPT) based national policy and the WHO guidelines, including the use of a clinical screening tool to identify individuals at risk for active TB and providing IPT to HIV-infected persons who do not have signs and/or symptoms of active TB. This project’s goal was to conduct operations research on ACF and IPT in the antenatal clinic context by assessing the progressive roll-out of ACF among HIV-positive and HIV-negative pregnant women and measuring the uptake of IPT among women in whom active TB has been excluded. Results were presented in an oral presentation at the International TB Union meeting in Kuala Lumpur in 2012, and a manuscript was accepted for publication by the Journal of Acquired Immunodeficiency Syndromes (JAIDS).

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Towards Getting More HIV-Positive Infants on Lifesaving Treatment: Measuring HIV Test Turnaround Times and Early Effectiveness of HIV Mother-to-Child Prevention Programs Using Early Infant Diagnosis Records (Private: 2012)

In Lesotho, 37,000 children are living with HIV, and only about 38 percent are receiving lifesaving treatment. Historically, there have been gaps in coverage for early infant diagnosis (EID) of HIV and early infant treatment (EIT) services in Lesotho (especially in rural areas), with long turn-around-times identified as a significant challenge. The aim of this research study was to describe the current EID process, early MTCT infection rates, and the PMTCT services received by HIV-positive mothers and their infants who had an HIV test at six to eight weeks in selected sites in Lesotho in order to determine necessary steps to improve early initiation of HIV-positive infants into antiretroviral (ARV) treatment programs. Results were presented in an oral presentation at the International AIDS Conference in Kuala Lumpur in 2013.

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Pilot Test of HIV and Infant Feeding Indicators (WHO: 2011 to 2012)

Breastfeeding is a direct route of HIV transmission from HIV-infected mothers to infants, yet there is no standardized indicator on the infant feeding practices of HIV-exposed infants. EGPAF received funding from the World Health Organization to conduct a pilot evaluation of infant feeding indicators within the context of maternal, neonatal, and child health postnatal services in select sites in Lesotho. The objective of the evaluation was to determine whether the indicators were feasible to collect routinely at primary health care facilities and whether they reflect the actual feeding practices of HIV-exposed infants. Study results will be presented in an abstract at the International AIDS Conference in Melbourne in 2014 and in an oral presentation at a related pre-conference meeting.

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The Impact of HIV Test Results on Subsequent Antenatal Care Attendance by Women in Rural Hospitals in Lesotho (Private: 2010 to 2011)

Regular antenatal care visits beginning early in pregnancy promote safe motherhood, particularly for HIV-positive women. While many factors affecting antenatal clinic attendance have been documented, the aim of this study was to explore the impact of a positive or negative HIV test result at a woman's first antenatal clinic visit on her subsequent clinic attendance, for which existing research was limited. Women's antenatal clinic visit records in three rural hospitals in Lesotho were reviewed and information on the number of antenatal clinic visits, gestational age at first visit, HIV status, maternal age, CD4 count, and the receipt of ARV prophylaxis or ART for HIV-positive women was collected. Results were presented in a poster presentation at the International AIDS Conference in Washington DC 2012.


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Promoting Good Health for Mothers and Babies (UNICEF: 2010 to 2011)

With funding from UNICEF, EGPAF supported the MOH to improve the quality of services offered to pregnant women by integrating PMTCT into maternal, neonatal, and child health services and scaling up pediatric HIV care and treatment. More than 1,110 infants were initiated on cotrimoxazole prophylaxis during the project period. EGPAF trained 375 health care workers on infant and young child feeding, counseling, and support. Fifty-seven nurses were trained on comprehensive pediatric care and treatment, and 17 nurses were trained on the new WHO PMTCT guidelines. EGPAF conducted onsite mentoring on monitoring and evaluation, presumptive diagnosis of severe HIV disease in young children less than 18 months, and infant and young child feeding. Child Health Days were introduced nationwide and offered HIV testing and counseling, including early infant diagnosis (EID), TB screening, nutrition assessments, and distribution of vitamin A. Child Health Day campaigns reached over 11,559 children.

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Call to Action (USAID/PEPFAR: 2004 to 2010)

With funding from USAID and PEPFAR, EGPAF implemented the eight-year global Call to Action (CTA) Project in 12 countries, including Lesotho. CTA significantly contributed to national PMTCT achievements. EGPAF's work in Lesotho was based around four areas: expanding coverage of HIV/AIDS services; ensuring high-quality services; building community support for program sustainability; and providing support at the national level. Over the course of the project, EGPAF assisted the MOH in establishing and enhancing PMTCT service provision at 103 health facilities in six districts (Berea, Butha-Buthe, Leribe, Maseru, Mokhotlong, and Thaba-Tseka). In the five districts where EGPAF was the only PEPFAR clinical services partner, coverage was successfully increased to 100% for PMTCT. Under the project, more than 55,000 pregnant women were provided with HIV testing and counseling services, approximately 17,000 women were provided prophylaxis for PMTCT, nearly 15,000 infants received drugs to prevent HIV acquisition, and almost 8,000 infants were tested for HIV using DNA/PCR testing.

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EGPAF Country Fact Sheet: Lesotho: Download PDF download

Lesotho Program 2013 Annual Report: Download PDF download

Country adaptation of the 2010 World Health Organization recommendations for the prevention of mother-to-child transmission of HIV: Download PDF download

Data Validation as a Way of Closing the Gap Between Reported Aggregate Data and Client Level Health Facility Records, by M. Khang, P. Tsokeli, N. Poopa, A. Isavwa, M. Ramoseme, A. Tiam : Download PDF download

How Much Will It Cost Lesotho To Move From Option A To Option B+ Of The World Health Organization's Prevention Of Mother-To-Child Transmission Of HIV Guidelines? by Mbetu T, Tiam A, Nchephe M NCHEPHE, et al. : Download PDF download

Impact of the Partnership for Management Development (PMD) program on facility-based deliveries in Lesotho, by Olowolabi O, Oyebanji O, Ahimbisibwe A, Isavwa T, Tiam A : Download PDF download

The 2013 World Health Organization Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection : Download PDF download

The Role of Research in Achieving Virtual Elimination of HIV Infection in Children: An EGPAF Perspective : Download PDF download

Toward Elimination of New HIV Infections in Children: Progress, Challenges, and Opportunities : Download PDF download

Using Data to Understand and Address Gaps in the Treatment Cascade for HIV-Positive Infants and Young Children: Experiences from Lesotho, Malawi, and Swaziland: Download PDF download

Site Profile: The Senkatana Centre of Excellence and the Botsabelo Complex: Download PDF download

Haba Na Haba: Technical Assistance Provision at the Elizabeth Glaser Pediatric AIDS Foundation : Download PDF download

Haba Na Haba: Spotlight on Pediatric Care and Treatment: Download PDF download