N/A

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 02 - HVAB Sexual Prevention: AB

Total Planned Funding for Program Budget Code: $700,000

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

OVERVIEW:

UNAIDS estimates indicate that Lesotho has a prevalence of 23.2%, the third-highest HIV/AIDS prevalence in the world. Further,

results from the 2004 DHS indicate that 26% of women and 19% of men aged 15-49 are HIV-infected. Prevalence rises with age

among both sexes, peaking at 43% among women in their late 30s and 41% among men aged 30-34. In all ten districts of

Lesotho, women have a higher infection rates than men.

By the age of 18, 47% of young women and 52% of young men have had sex. Gender inequalities are thought to fuel the HIV

epidemic, with culturally ingrained gender disparities adding substantial burden. The last DHS (2004) revealed that both 48% of

women and 51% of men agreed that wife beating is justified. The recent UNAIDS and USG-funded Multiple Concurrent Partners

(MCP) study revealed that 38% of those who are sexually active have multiple concurrent partners (2008). Eleven percent of

women aged 14-49 years and 30% of men aged 15-59 years have had two or more partners in the last year (DHS, 2004).

According to a WHO study cited by Halperin and Epstein, concurrency was even higher, with women‘s rates being reported at

39% and men's rates at 55% (2007). Despite these high rates of multiple concurrent sexual partnerships, cultural norms restrict

public discourse on the sexual behavior. The job market adds to sexual networking environment with the all-male mining industry

and the predominantly female textile industry often displacing workers from their home villages and thus contributing to the

likelihood of multiple sexual partnerships.

Despite the stated emphasis on prevention in Lesotho's response to HIV/AIDS, many of the local stakeholders interviewed for this

COP narrative expressed doubts about the feasibility of promoting each one of the "ABCs" of prevention: Abstinence, Be Faithful,

and correct and consistent Condom usage. The 2002 reproductive health survey indicated that amongst 20-34 year old females,

about 28% of women who said they were abstaining to protect themselves had actually had sex in the past four weeks. The MCP

study revealed that 38% were engaging in concurrent relationships, 46% in monogamous relationships and 9% are those who

said that they are sticking to one partner to protect themselves (2008). In the recent Modes of Transmission study, it was clear

that little has changed since 2002: over the next 12 months, 65% of all new infections in Lesotho will come through "casual sex"

and 23% through "low risk" situations through people involved in sex with a single marital or cohabitating partners (2008). Thus,

seven out of eight infections will be linked to multiple concurrent partnerships. According to the MCP study, a number of factors

influence the high rates of concurrency, including alcohol, finances, dissatisfaction with current partners, and a belief that

faithfulness to a partner need not include sexual faithfulness, as long as one provides support and respect (2008).

MOHSW staff and Basotho prevention specialists interviewed during the COP planning process described abstinence, fidelity,

partner reduction, and correct and consistent condom use as impractical or unrealistic, based either on their assessments of

prevalent culture norms, or on concerns pertaining to empowerment and gender. In particular, young women were cited as being

poorly positioned to abstain from sex or to negotiate condom use. Fidelity and partner reduction were identified as important ways

to prevent new infections and even ecouraged, but were seen as having limited impact due to the perception that it is normal to

have more than one partner, and that those who adopt these strategies may still face exposure via the risk behaviors of their main

partner. The achievement of correct and consistent condom use was seen as unlikely in the context of regular, transaction, and

"trusted" partnerships that probably contribute most to new infections in Lesotho.

In Lesotho, correct and consistent condom use among those reporting more than one sexual partner in the past two months was

48.6% for men and 41.9% for women aged 15-49 (BCC 2008). Over the past decade there has been a marked change in

attitudes toward condom use for disease prevention. Demand for condoms has soared with a stated 22 million condoms having

been distributed (PSI 2006). About 80% of women and 70% of men know that condom use can reduce the risk of contracting HIV

during sexual intercourse (LDHS 2004). All the same, there are still low levels of condom utilization due to misconceptions and

myths associated with their use, as well as supply chain issues that are impacting availability. A 2007 Global Fund assessment

also indicated a major shortfall in total numbers of condoms available in Lesotho. A more recent assessment conducted in several

districts by the Government of Lesotho (GOL) in collaboration with the United Nations Populations Fund for Population Activities

(UNFPA) indicated that major logistics supply problems exist, with stock-outs in some facilities and tremendous over-stock in

others.

Over the past five years, (GOL) has made access to treatment a national priority. Unfortunately the most glaring gap in the

national response remains the prevention of sexual transmission. The 2006-2011 Lesotho National Strategic Plan (NSP), states

that "the focus of the NSP is… to enhance prevention by increasing quality of interventions through behavioral change

communications strategies," and recognizes that multiple and concurrent sexual relationships are primary drivers of the epidemic.

Since the current NSP was initiated, however, GOL's "Know Your Status" campaign (2005- 2007) has been the government's

primary prevention strategy. This national effort to provide access to community-based VCT provided few explicit prevention

messages outside of individual counseling, and since its end, there is a lack of explicit prevention messages delivered through

both counseling as well as mass media channels. As a result, the PEPFAR/Lesotho has placed strategic priority on scaling up of

sexual prevention programs at national, district and community levels. The USG will implement its prevention programs through a

cohesive plan that promotes stronger programmatic linkages to all prevention, care, treatment and support partners. GOL will

soon release a national BCC strategy and the BCC interventions will catalyze and mediate all programs in Lesotho.

CURRENT USG PROGRAMS:

In FY 2008, PEPFAR/Lesotho implemented its prevention programs through a cohesive plan that promoted stronger

programmatic linkages among all prevention, care, treatment and support to partners. In September 2008, the new Prevention

Specialist arrived, and she is providing leadership to all PEPFAR partners on prevention messaging. She is managing prevention

partners to ensure a more harmonized and comprehensive USG prevention program that closely collaborates with MOHSW and

NAC. In addition, the Prevention Specialist is leading the recently formed PEPFAR Prevention Technical Working Group (PTWG).

The TWG serves as a program-wide forum for sharing information and best practices, discussing priorities and formulating

strategies.

AED's C-Change project is working with local stakeholders to develop comprehensive prevention messaging. They conducted a

prevention priorities workshop of which guided their prevention strategy. AED's focus is adults with multiple concurrent partners

and youth, to impact future behaviors. Peace Corps, working with several host country partners including the Ministry of Youth,

Gender, Recreation and sports, the Lesotho Basketball Association, and local businesses, is using sports as a medium for

transferring critical life skills and HIV/AIDS prevention strategies to youth. Peace Corps is continuing its HIV/AIDS prevention

education program through sports camps and Speak ALOUD, a gender and youth workshop examining emerging gender and

youth roles and how they relate to HIV /AIDS. Under the International Labor organization (ILO), HIV/AIDS workplace programs are

supporting construction, security, utility and hospitality enterprises and have developed BCC strategies that include AB messages.

Through its sub-grantees, Pact is strengthening the capacity of volunteers, peer educators and teachers to deliver prevention

messages to community beneficiaries. Pact sub-grantees are also working with religious leaders to reach congregations with

values-based prevention messages for men and women, and promoting CT and the use of other preventive services. PSI

provides condoms through their nation-wide distribution network. Between January and August 2008, they distributed 1.3 million

condoms donated by USG throughout Lesotho, and they plan to continue distribution with FY 2008 funds. The DOD program with

the Lesotho Defence Force focuses on peer based troop level prevention programs and working with LDF officers to enhance HIV

knowledge and support for prevention programs focusing on male norms for prevention.

USG FY2009 PROGRAMS

In FY 2009, USG's strategy is to engage one partner (AED's C-Change project) to coordinate effective and sustainable

communication messaging for all prevention partners. C-Change's messages will be distributed in multiple fora (mass media,

interpersonal communication, VCT, religious settings, etc) and will particularly target multiple concurrent relationships,

transactional sex, and intergenerational sex as they are common practices in Basotho culture. Messages will be targeted to both

men and women currently involved in MCP, as well as youth as a means of reducing the likelihood of future MCP behaviors.

Fundamental to this approach is a grassroots program that works through existing structures and systems such as churches,

community councils and local organizations and includes discussion and reflection with intensive mass media support.

Other partners will work within this overall framework to convey prevention messages, coordinating closely and following the C-

Change lead in providing consistent messages to target groups. As the Pact contract is ending, PEPFAR/Lesotho will identify a

follow-on umbrella organization to coordinate ABC efforts among small, local NGOs. This TBD partner will link with C-Change to

provide all TA related to facilitating the development and coordination of prevention-related messages across all target

populations. As soon as the new umbrella organization is identified, it will work very closely with C-Change and make sure that the

sub-partners are fully informed of prevention messaging strategies and that their approach is completely aligned. Messages for

local and international faith-based organizations will follow the C-Change model, with modifications to suit specific religious

beliefs. Peace Corps, through its program Men As Partners program, will target men between the ages of 15-45, engaging them

through workshops that address issues of gender norms and the current cultural contexts contributing to the epidemic. DOD

programs will work with the Lesotho Defence Force men and women, and the civilian communities that they serve.

PSI has diversified its line of condoms according to income-based market segmentation and ensured availability and promotion of

condoms to each segment. During the last condom campaign, Lesotho had generic messaging promoting general condom use.

PSI's annual MAP (Measuring Access and Performance) tracks the entire condom market in Lesotho. Phase II of the MAP study

was completed in October 2007 and has demonstrated a significant increase from 11% in 2006 to 39% in 2007 in coverage in

rural areas where district-based sales agents were deployed based on the findings of the MAP I study. Coverage in all designated

high-risk areas (CSM's/near border posts/factories) is over 90%. PSI also approaches market development by giving samples to

new micro-vendors to generate profits to be used for future procurement of condom stocks.

In FY 2009 PSI will incorporate messages on multiple concurrent partnerships and will coordinate this messaging with C-Change

to ensure maximize impact. PSI will also develop a life skills communications initiative with the existing implementing partners'

activities. PSI will continue to train peer educators within the Lesotho Defense force.

LEVERAGING/WRAPAROUNDS

USG and UNAIDS jointly financed MCP study has been completed and the findings have been shared with all stakeholders in

October 2008. The findings will inform prevention messaging in a way that is locally driven and locally owned.

Working with NAC and other stakeholders, PEPFAR/Lesotho will participate as a member of the national prevention working

group responsible for planning and implementing a nationwide BCC strategy. The BCC strategy will include the various in-country

prevention partners, a delineation of partner roles, and identification of mass media channels to be used to influence social norms

and address stigma and discrimination, and a strategy for reaching all appropriate target audiences. All USG Prevention

messaging, including correct and consistent use of condoms and male circumcision will be integrated across the program.

PROPOSED COMPACT ACTIVITIES

As PEPFAR/Lesotho moves forward to negotiate a Partnership Compact with GOL, we anticipate that prevention, particularly

BCC, will be a major focus. As noted above, GOL's prevention program has been weak-to-non-existent. We anticipate negotiating

with GOL to reach mutual agreement on how to strengthen the National BCC policy and services, with a goal of reducing

incidence of HIV in Lesotho. Commitments and responsibilities will be linked to the implementation of the National Strategic plan

and soon to be released National BCC strategy. We plan to address gender issues within the context of prevention and

strengthen prevention across sectors by linking with health and other development programs, as noted in the Guidance

documents we received from the Deputy Principals. As Compact negotiations are only at the early stages, we understand that we

may need to revise expectations, and will be in touch with our core team and DP "friend" as we move forward.

OTHER QUALITATIVE ACCOMPLISHMENTS

• Condom distribution Strategy adopted by MOHSW by sept.2009

• Community MCP toolkit version 2 developed by june2009

• Couples IPC toolkit developed by April 2009

• Youth IPC tool kit developed by 2009

Table 3.3.02:

N/A

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.02: