Why Lesotho is losing the AIDS fight

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Tsitsi Matope

In Lesotho, HIV/AIDS is like a stubborn migraine that never goes away. According to some activists, the last two

Teboho Mohabi

Teboho Mohabi

years have been particularly dangerous for the country as funding for anti-HIV/AIDS programmes has systematically dwindled.

Lesotho has since leapfrogged Botswana into second place as the country with the highest Human Immunodeficiency Virus(HIV) prevalence in the world, although the figure still remains at 23 percent, while Swaziland leads the pack at 26 percent, and Botswana is now at 19 percent.

The latest official figures also indicate that 62 people are infected with HIV on a daily basis in Lesotho, while 50 deaths related to the Acquired Immunodeficiency Syndrome (AIDS) also take place every day in the kingdom.

The Lesotho Times (LT) this week met with Teboho Mohlabi—an HIV/AIDS researcher and activist who lobbies for the efficient management and coordination of AIDS interventions—to discuss the current situation, political will to combat the epidemic and what he foresees on the horizon as far as the disease is concerned for Lesotho.

LT: Various stakeholders working in Lesotho’s HIV/AIDS sector have come a long way in their fight against the epidemic. Do you think more could have been done to change the current dangerous tide?

Mohlabi: I think we could have done better and done more. Somewhere along the way, the push slackened and relaxed. As a country, I think some people shifted their focus to other things and forgot to act responsibly. I will maintain that even when we were at the height of our interventions when we had many Non-Governmental Organisations (NGOs) based here and lots of donor-funding, we did not exert our interventions enough. There were some misplaced or not well-thought-out priorities, particularly in the area of workshops, for example. For years, many stakeholders attended workshops locally and internationally and many of them, if they are to be honest, would share my sentiment that some of them were an unnecessary repetition of previous workshops and therefore, a waste of resources, which could have been used in neglected areas.

LT: Can you take us through Lesotho’s fight against the epidemic from the beginning?

Mohlabi: It has been a long and complex journey for various stakeholders. And that the latest figures show very little progress in terms of reducing the 23percent prevalence rate and new infections, is disappointing.  HIV was diagnosed for the first time in Lesotho in 1986 but a lot of people remained in denial for many years. In the years preceding the early 2000s, many people died and it was clear that we had a serious challenge. Many patients could not access and afford the antiretroviral drugs. There was a lot of fear and the magnitude of the epidemic attracted a lot of international support and funding. Back then, we did not have the National Aids Commission and as a result, efforts to fight the disease were not that well-coordinated. But after the King declared AIDS a national disaster, followed by the then Prime Minister Pakalitha Mosisili who publicly tested for HIV, we started noticing the political will and proper structures emerging.

LT: The structures you mention include the disbanded National Aids Commission (NAC). Do you think it was a mistake to close it down?

Mohlabi: I think it was a mistake that the NAC was closed because its mandate, among others, was to coordinate all programmes related to HIV/AIDS in the country. The challenge is that no one is coordinating these efforts; it’s now all haphazard.

Recently, there has been a talk regarding efforts to resuscitate some of the key functions that were being undertaken by the Commission. Personally, I think there is no other way we can move forward unless we can have one coordinating body. The best thing the country can do now is to follow the recommendations made before the NAC closed shop (in December 2011). The recommendations did not say the commission should close but that it should downsize at headquarters and deploy more people in the districts where the house was burning.

LT: Where do you think Lesotho could have lost the plot in the fight against the epidemic?

Mohlabi: There are a lot of things that have gone wrong in the fight against HIV and AIDS in Lesotho. The closure of the NAC, instead of restructuring it, was one of them. Yes, there was a lot of promise when many organisations started working in the HIV/AIDS sector but this slowed down when the AIDS fatigue gripped many people. There was no hiding the fact that many people were tired of hearing the same messages over and over again. I remember during some awareness campaigns, the audience would start yawning. I believe messages had become routine and monotonous. At organisational level, there were also signs that some had run out of steam or ideas. After noticing the fatigue, many organisations made little effort to stimulate the momentum. Importantly, another contributing factor was the limited funding of the Lesotho Network of People Living with HIV/AIDS (LENEPWHA), which disjointed efforts. LENEPWHA is the only organisation that truly represents people living with HIV through its support groups situated across the country.

LT: Is funding for HIV/AIDS programmes currently a major concern?

Mohlabi: Yes, lack of funding is a big concern amid our current dire situation. There is still a lot of work to be done and there is no money. A lot of HIV/AIDS organisations have either closed or down-sized their operations. I dread to imagine the possibility that we might not receive more money from the Global Fund. We are getting funding under Round Eight of the Fund, which is ending in December this year.

LT: How do you explain the scarce funding? What has caused the donors to hold back when the situation is obviously still desperate?

Mohlabi: It’s a combination of factors. Generally, we have been noticing the reluctance by some donors to fund certain programmes. For a few years, they cited the global financial meltdown, but even when we think the situation has improved, the trend is still negative. On the other hand, there are also spending concerns in some organisations. According to the latest National Aids Spending Assessment study, some organisations spent more than 40 percent of their funding on administration and these are costs associated with salaries, rent, electricity and others. What this means in many cases is that some organisations exceeded the recommended expenditure which says only between 20-30 percent is to be used for administration and the rest of the money on programme-implementation.

LT: In what areas would you say much of the donor-funding was utilized over the past few years?

Mohlabi: There were a lot of trainings and awareness campaigns in many parts of the country, although we still have areas that were not covered. A lot of NGOs have their head offices in Maseru and small offices in the districts, ironically where the majority of the people live and are in desperate need of services.Interventions also targeted different vulnerable groups and households affected by the epidemic for various support and HIV testing and counseling.  Well, there is no denying that in some instances, there was a lot of repetition of programmes. I think that goes to show the importance of proper national programmes coordination.

LT: You spoke of a duplication of programmes…was it because it was difficult for organisations to collaborate their efforts in order to maximise the utilisation of resources?

Mohlabi: Collaboration by different groups running similar programmes is a good innovation which I think organisations that are still operating should explore for future projects. However, this was not really the case in the last few years where we have seen some organisations actually competing. In some instances, this divide might have been caused by various factors related to requirements stipulated by some donors.

LT: How much confusion and questionable activities have you noticed in the sector over the past few years?

Mohlabi: I think there is still a lot of confusion even now and much of it could have resulted from inconsistencies and the manner in which messages were and are still being communicated in various departments. I think the lack of monitoring of counselors to establish their level of competence is also a challenge in some areas. While counseling is confidential, it is also not easy to do outreach programmes meant to follow up on patients to assess the impact of work done. In some cases counselors are under pressure to meet certain targets per specific periods. This can compromise the quality of counseling. The consequences of poor counseling can be devastating.

LT: While still on counseling, how many times, on average, should a person who would have tested positive for HIV be counseled?

Mohlabi: It depends. A professional counselor should be able to tell how many counseling sessions are needed for each patient based on the assessment. People are different because there are some who accept their situation after a few sessions while others can take time. On average, eight sessions are acceptable.

LT: You were explaining some areas you felt there was failure to hit the target…

Mohlabi: There are several such areas. If you look at the boom in clinical male-circumcision, you would think all the men being circumcised understand why they are undergoing such an operation. The truth of the matter is that not all of them understand why they should wear condoms when they are medically circumcised and also when not circumcised. When you talk about a 60 percent HIV risk reduction for men who are medically circumcised, there is need to break it down for a layperson to understand what this means. Some men can interpret this to mean they will have to have sex 60 times without a condom before they can get infected. As a result, we are seeing many men getting circumcised but sadly, for the wrong reasons. What we need is to revise how we communicate messages to avoid achieving the opposite of the intended objective. The other area we have failed to deal with is behavior-change. I think we need to go deeper and have a clear understanding of what is driving the epidemic and then formulate additional strategies that are more practical.

LT: Where should behavior change interventions start from?

Mohlabi: I think it’s important to understand that we are people who do not openly speak out about sex issues. In some churches too, discussing condoms has proved impossible, let alone a chief standing up in front of a crowd and discuss condom-use. So it is about our attitude and our way of life we should deal with and see how we can then break those barriers and hit the target. What has been the result of these half-measure efforts has been the stubborn development of attitudes that say what kills you later in life does not matter or a disease that can be managed is like any other disease. Now that we know what kind of people we are, I think we should start getting serious with our interventions beginning at primary school level. We should start teaching HIV/AIDS early because some children are engaging in sex as early as 13 years, which is something that should terrify everyone who cares about the wellbeing of this country. Schools should prioritise life-skills education because that is the foundation that would enable children to make good decisions, solve problems and not bow to peer-pressure. The techniques used can help both boys and girls to have self confidence, value themselves and say No to early sex.

LT: What role can be played at household level to fight HIV/AIDS?

Mohlabi: A very crucial role. We can penetrate difficult areas through household structures before we can even begin talking about efforts at community level. The scenario at the moment is that different parents and guardians are teaching children and also among adults they do advice and remind each other of the importance of responsible behaviour. The degree of such teachings differs from one household to the other. However, if the truth may be told, the reality on the ground is worrisome, considering how busy most people are these days. Parents and guardians come home late and when they are home, they bury their heads in their laptops or are on their smartphones. To compensate for their absence even when they are at home, they pay for all television channels to please the children. I think a good and immediate intervention would be for schools to give children homework that would require the involvement of the guardians. Such tasks should be related to HIV/AIDS, other sexually transmitted illnesses and other reproductive health matters.

LT: What role can the private sector play in strengthening the fight against HIV/AIDS?

Mohlabi: Although they have a critical role to play in helping sustain interventions, the private sector has, over the years, not really come out strong in supporting HIV/AIDS programmes.  The sector can do a lot of work as part of their corporate social responsibility. In other countries, instead of companies paying tax to the revenue authority, they have the option to come up with a plan showing how they would like to use the tax or part of it to support vulnerable groups. We can replicate such models to stimulate the involvement of the private sector in programmes that also affect the sustainability of their businesses.

LT: Finally, which areas do you think we need to strengthen to ignite the fight against this epidemic?

Mohlabi: We need to re-organise the sector, re-strategise and come up with new and smart innovations that can directly respond to the factors fueling new HIV infections. We need to be more serious and realistic about what we can achieve in the various terms (short, medium and long term). As a country, we also need to take issues of transparency and good governance seriously to stimulate economic growth and reduce poverty and vulnerability. We also need to see more action that reflects a high level of political will in the fight. Yes, we need funding but we have seen how funding alone cannot reduce new infections without well thought-out programmes. As a people, what we desperately need is a wave of behaviour-change towards sex. We need to regard seriously, and as a matter of life and death, the strong sense of responsibility that is demanded in our relationships.

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