‘We need to tackle poverty and inequality to end HIV endemic…’

While remarkable progress has been made in the fight against HIV/Aids, ending the epidemic will likely take longer and with more than drugs. That’s because the main driver of the disease has more to do with social inequity than with the virus alone. This is the reason Public Eye reporter, LINEO MABEKEBEKE (PE) engaged the National Aids Commission’s (NAC) LEBOHANG MOTHAE (LM) to talk about ending HIV-related social inequality as a step to total eradication in the country.

PE: We are aware that the NAC and partners are currently creating public awareness of inequalities in HIV/Aids response, considered to be hindering the country’s progress. What steps have you embarked upon to this end?

LM: We have embarked on the sensitization of HIV stakeholders including lawmakers, decision makers, community leaders and implementing partners and Basotho at large.

Reinforcing multi-sectoral response and coordination through capacity building of special interest forums, the National HIV and Aids Forum, National Religious Leaders Forum and the Civil Society Organizations (CSO) Forum, as well as District Aids Committees, the Media fraternity and HIV implementing partners.

We launched the development of standardised youth-focused HIV prevention messages, Community Monitoring Evaluation and Reporting guidance and a Community Dialogue Guide to strategically guide interventions for HIV prevention and community HIV service provision. And also facilitating community led response through engagement of community leaders, CSOs and youth representatives

PE: What are these inequalities?

LM: The UNAIDS definition of inequalities encompass the many inequities (injustice or unfairness that can also lead to inequality), disparities and gaps in HIV vulnerability, service uptake and outcomes experienced in diverse settings and among the many populations living with or affected by HIV. The most prevalent ones in Lesotho are:

• Geographical whereby due to the topography of Lesotho, some places are remote and hard-to-reach making it almost impossible for certain populations such as pregnant women to access requisite services that would prevent transmission of HIV from mother to child.
• Gender/Sex – The most disproportionate group of people in the country with high incidence and prevalence of HIV is that of females. Additionally, key populations such as LGBTQ are not officially classified and this may hinder programming that is responsive to their needs and lead to discrimination and therefore fear of accessing services.
• Age – 80 percent of new infections is among young people with adolescent girls and young women being disproportionally affected. Young people are afraid to access HIV and sexual and reproductive health (SRH) services because of fear of stigmatization by health professionals and the society at large. They are further confronted with several socio-economic factors such as unemployment, early marriages, transactional sex that pose risks of new HIV infections and STDs.
• Populations – Lesotho’s population is increasingly becoming diverse and includes key and vulnerable groups such as LGNTQ, female sex workers (FSW), men sleeping with women (MSM) who are subject to discrimination, violence, and punitive legal and social environments, each of which contributes to HIV vulnerability.
• Services – The country, through the Ministry of Health and partners, has made significant strides to improve HIV services across the cascade from HIV testing, treatment and care as well as impact mitigation. Challenges still remain due to persisting inequalities caused by among others, geographical location, sexual orientation and economic status.
• Laws and policies – there are some laws in the country that stigmatize and criminalize people living with HIV and key populations such as FSW and MSM thereby exposing them to some vulnerabilities that impede their access to services and opportunities that would otherwise decrease such vulnerabilities.

PE: How best should efforts be to end the inequalities that prevent people from accessing healthcare?

LM: We should go all out to end inequalities from the levels of individuals to families, communities and the nation at large. Inequalities denote injustice, unfairness and prejudice and no one must be subjected to such.

Therefore, we must apply a gender and human rights lens to give due recognition, consideration and respect for all people of this country. We should continue to assess the legal, social, cultural, economic and political practices and environments to keep in check of related inequalities; we need bold decisions in all societal institutions such as government, churches, schools, families etc to facilitate behaviour changes that reduce risks and vulnerabilities of young people.

We should be a shared leadership wherein everybody in their own corners assume responsibility towards ending inequalities; Accountability mechanisms must be effective to provide checks and balances necessary to reduce imbalances; Partnerships and collaborations must be improved at all levels of the response and communities must lead the response and processes of ending inequalities in their respective areas, local solutions to local problems.

 PE: How do these hinder progress in the fight against HIV?

LM: People are being locked out of the right to health, well-being and to dignity because they are marginalised and criminalised. Those affected by inequalities are constrained from accessing and using the most needed services. Funding and other investments are limited in the existence of inequalities.

PE: What measures are in place to avoid the outlined inequalities?

LM: Prioritize HIV as an integral development agenda to enable resources mobilization and distribution for HIV response. Put people living with and affected by HIV at the centre of the response to ensure that interventions are targeted and responsive to the needs of the people.

Reinvigorate the multi-sectoral response and avail a platform for all interventions need by individual Basotho in their own uniqueness.Advocacy measures to eliminate laws and policies that discriminate and stigmatise other population groups with specific focus on people living HIV, key populations and young people. While also collaborating with and build the capacity of civil society organizations to amplify the voice of the communities.

PE: How many lives are put at risk by failure to achieve balance of these inequalities?

LM: Without quantification, lives of the following groups are put at risk as inequalities widen and persist: People living with HIV, adolescent girls and young women (AGYW), adolescent boys and young men, key populations and their partners, internal and external migrants as well as the general population.

 Looks like we are all affected and therefore at risk even though it is with different magnitude. We must end inequalities to afford Basotho an Aids free generation.

 PE: We have just been thrown off-balance by the Covid-19 pandemic, how has the epidemic exposed Basotho to social and economic inequalities?

LM: Unemployment levels increased and thus increasing economic inequalities such as low income levels, lost jobs and limited spending capacity that serve as barriers to access to services and decreased bargaining or negotiation power for protected sex due to loss of income.

Skewed distribution of financial resources as more attention and focus was on Covid-19 due to its emergent nature. Young people being out of school increasing vulnerability exposure to early marriages, early and unintended pregnancies all leading to possible HIV infections.

Poverty levels have increased and may lead to increase in transactional sex which is one of the drivers of HIV infections. There have been high reported cases of sexual and gender based violence and intimate partners’ violence. Though yet to be determined, mental health challenges seem to be in the rise posing a threat of stigma and discrimination.

Today, the HIV/Aids epidemic is described as concentrated, meaning that despite the decline in HIV prevalence in the general population, there is a concentration of the epidemic in specific groups – what is our situation in the country with regard to this concentration? Discrimination, gender inequality, poverty, and criminalisation are all barriers that can prevent them from accessing healthcare, how do we fare as a country?

PE: And how have key populations been affected; some people suggest extremely?

LM: Indeed, because of fear of discrimination and stigmatization, limited KP friendly services and providers thereof, lack of basic legal protections. Also included therein are vulnerable groups such adolescent girls and young women with reported school dropouts, early and united pregnancies, unprecedented abortions, early marriages and resort to transactional sex.

PE: Doesn’t this jeopardise the capacity to control the epidemic?

LM: All acts of stigma and discrimination, violence, injustices and prejudice against people hinder progress towards ending Aids as that is associated with new infections and Aids related deaths.

PE: How best can focus on strengthening the health system to remove stigma and social justice barriers and ensure key populations have access to adequate HIV services be increased?

LM: Firstly, we need to decriminalise laws that are punitive to key populations such as FSW and MSM. Apply human rights and gender lens in all HIV interventions. Involve the civil society organizations that have already established rapport and understand the community dynamics as well as the needs of key populations. Engage key populations peers and key population competent organisations to deliver HIV services in a safe space.

We need to also continuous training of health professionals on key populations sensitive and friendly service delivery models and methods, as well as scaling up of differentiated models of service delivery and innovations that maximise protection of key populations.

PE: Please outline detail concrete actions that should be taken to ensure total eradication of the HIV/Aids endemic?

We can start first by closing the tap of new infections by removing all forms of barriers and inequalities. HIV prevention should be given extraordinary urgency and focus and therefore use of combination prevention methods is highly recommended and then engage communities to invigorate community led responses and ownership of the response and interventions therein. Then move to bolster multi-sectoral response for comprehensive interventions for all population groups. Keep girls in school and improve their protection and improve male partner engagement for their involvement in and support for HIV prevention initiatives.