MASERU – Lesotho is one of the countries, most severely impacted by HIV/AIDS in the world.
With an HIV prevalence rate of over 25 percent, the HIV burden in this country is among the highest in the world.
An estimated 330 000 people out of the two million population were living with HIV in 2016, when 9 900 people died from AIDS-related illnesses.
The United Nations Children’s Emergency Fund (UNICEF) in November 2017 indicated that the high prevalence of HIV and AIDS “accounts for more than 40 percent of all deaths in Lesotho”.
Evidence from various studies have shown that Voluntary Male Circumcision (VMMC) reduces a HIV-negative men’s risk of HIV infection by up to 60 percent in combination with general HIV prevention strategies, such as condom provision.
Following these studies, VMMC was promoted as an effective HIV prevention strategy in Lesotho.
Yet, in Lesotho, the most common type of circumcision is not performed in a clean or safe setting by trained health professionals.
Some Basotho men still prefer to be circumcised traditionally in initiation schools during the rite of passage to manhood.
In January this year, Avert – an international HIV and AIDS charity based in Brighton, United Kingdom – indicated that in 2017, Lesotho’s VMMC programme aimed to circumcise 38,737 men aged 15 to 29 years.
This would have achieved 80 percent saturation in two of the five districts (Berea and Maseru) with the remaining three districts scheduled to reach 80 percent coverage by September 2018.
“In total, 25,150 VMMCs were carried out in 2017, around 13,500 short of the target. A key challenge facing Lesotho’s VMMC programme is a lack of demand. This is largely due to the fact that traditional male circumcision, conducted during rites of passage ceremonies in which adolescent boys transition into adulthood, is popular in some parts of the country,” noted Avert.
Traditional initiation, known locally as lebollo, has from time immemorial been a crucial step in the development of a Mosotho child.
It has been an important part of Basotho culture that has for ages been respected, protected and preserved.
According to historians, initiation schools were equivalent to universities, preparing boys for their adult responsibilities as husbands and fathers, as guardians of cattle and as warriors and loyal subjects of their respective chiefs.
Traditional schools are conducted over a period of time, varying from a few months to six months in secluded areas away from the settlements.
The initiates are separated from all social activities and kept in a secluded place, usually on top of a mountain where their transition from boyhood into manhood takes place.
This means that during the initiation period, the initiates who are already living with HIV and are on Antiretroviral Treatment (ART) are barred from visiting health facilities for antiretroviral (ARV) drug refills.
Recommended HIV prevention and treatment services are typically unavailable in initiation schools.
According to the World Health Organisation (WHO), closed settings like initiation schools and prisons are a high-risk environment for HIV transmission.
Sometimes overcrowding, as well as malnutrition weaken the immune system, making people living with HIV in closed settings more susceptible to getting ill. Yet, initiates’ wellbeing is often neglected and overlooked.
HIV medication is taken at specific times of the day, and because initiates are not allowed to have either phones or watches on which to set an alarm for the time they take their HIV medication, they rely solely on instructors to remind them to take medication.
“We made a proposal to the Ministry of Health that it should consider integrating HIV care into initiation schools’ instructors. I believe this could result in significantly enhanced wellbeing among initiates living with HIV in our initiation schools. The ministry is not heeding our proposal,” Malefatsane Liau – an advocate for the upholding and maintenance of tradition told Public Eye.
Liau indicated that people living with HIV are admitted into the initiation schools but said such initiates were required to disclose their status to the owners of the respective schools.
“We take him to the mountain with his medication, and he is allowed to take the medication as prescribed by the western doctors. But you should understand that these people are under a care of instructors most of whom have not been trained on HIV or health issues in general.
“That is why it is important to have well-trained instructors accredited by the ministry of health. I for one have insisted that an instructor should not just be any person in the village who can sing, wears gumboots and smokes weed, as has been case in many initiation schools,” he said.
Liau, who is a leader of Lekhotla la Mekhoa le Meetlo (LMM), a group that promotes and defends Sesotho culture, also said parents should have a say in picking the initiation schools’ instructors.
“There must be clear and specific prerequisites which must include training on health for licensure. We did not have HIV long time ago when instructors were just chosen randomly by school owners. Now that we have HIV and many other diseases, we must be careful and protect lives. Life is more important than tradition and culture,” he said.
According to the National Guidelines for HIV and AIDS Care and Treatment (5th Edition), studies done across the world have clearly demonstrated that antiretroviral treatment is the best treatment for HIV so far.
ART reduces HIV-related opportunistic infections and cancers, deaths, as well as diseases not traditionally considered to be associated with HIV such as non-HIV related cancers, cardiovascular disease, kidney failure, and liver failure.
Suppression of HIV replication with ART reduces the risk of HIV transmission by over 90 percent, the guidelines further show.
These guidelines emphasise the importance of the HIV ‘care cascade’ – identifying people with HIV as early as possible after infection, promptly linking them to HIV care and beginning preparations for starting ART, and retaining them on treatment through robust adherence support and monitoring systems.
Lesotho in 2016 became the first country in sub-Saharan Africa to institute the Test and Start programme, which aims to put all people with HIV on ART.
Deputy Minister of Health ’Manthabiseng Phohleli this week told Public Eye that government had worked hand-in-hand with traditional doctors and made remarkable progress on making initiation schools safer for people living with HIV.
Phohleli said going to an initiation school used to be one of the factors influencing ART adherence but indicated that that was no longer the case suggesting that the HIV positive men at an initiation school were at no higher risk of failing to adhere to their treatment than their counterparts at home, school or at work.
“We used to have people who discontinued their HIV treatment because they had gone to initiation schools but that does not happen anymore. The Ministry of Health now has a Memorandum of Understanding with registered traditional doctors most of whom own almost all the initiation schools in the country.
“This Memorandum of Understanding affirms that initiation schools’ authorities have a duty of care to their initiates and an obligation to ensure that initiates have access to HIV prevention measures and treatment. We believe that response to HIV in initiation schools should be an integral component of national HIV strategy,” Phohleli said.
The deputy minister acknowledged however that no health education and training was offered to the instructors and said adequate training was provided to the traditional doctors.
“Traditional doctors are the ones who are conventionally responsible for the health of the initiates. That is why we provide training to them and we have a wonderful working relationship, not on HIV alone but even on Tuberculosis (TB). That is why we encourage all traditional doctors to be registered with the ministry of health so that they can get training,” she said.
The deputy minister further indicated that stable patients working on studying abroad are given ARV refills lasting three to six months, and the same was done to patients who wanted to go to initiation schools.
“We do the same to people who want to go to initiation schools so that they can be covered for the whole period they are separated from social activities,” she said.
Lesotho Population-based HIV Impact Assessment (LePHIA) that was conducted between November 2016 and May 2017, suggested that Lesotho has reached one part of the Joint United Nations Programme on AIDS 90-90-90 goal and that its national HIV response has been effective.
The UNAIDS 90-90-90 goal challenges each country to meet three objectives by 2020 — to have 90 percent of its people who have HIV know of their infection status, 90 percent of those who know their status on ART, and 90 percent of those on ART achieving viral suppression.
According to LePHIA’s findings, 81 percent of people living with HIV (ages 15 to 59) in Lesotho reported knowing their status, 91.8 percent of those individuals self-reported being on ART, and 87.7 percent of that group were virally suppressed.