Lesotho faces an immense challenge in the fight against HIV, as 23% of the population (or around 310,000 people) are currently living with the disease. According to the UNAIDS 2014 Gap Report, the scale-up of antiretroviral treatment (ART) in Lesotho has been gradual, however only 29% of adults aged 15 and older, and 15% of children younger than 15, are on an ART regime. Only 53% of all women living with HIV are receiving antiretrovirals for the prevention of mother-to-child transmission (PMTCT). More than 20% of men older than 50 who are living with HIV have never been tested. In 2013, the Ministry of Health and Social Welfare reported national human resources for health as 5 doctors and 56 nurses/midwifes per 100,000 people. In light of these facts, Lesotho has been adapting its service delivery model to include Lay Counselors – non-professional community members, often themselves living with HIV, who are trained to provide testing, counseling and adherence support. They have become a critical outlet to alleviate some of the burden felt by Lesotho’s limited cadre of medical professionals, and have regularly guided wary PLHIV since 2006.
LIFT activities began in Lesotho at the end of 2013 when project staff delivered a one-day household economic strengthening (HES) training to 25 community-based organizations in Thaba-Tseka and Mohale’s Hoek districts, two of the hardest hit by HIV, introducing participants to economic strengthening, livelihoods and food security (ES/L/FS) concepts and opportunities, such as creation and operation of village savings and loan associations (VSLAs). Since then, LIFT has worked to promote improved health outcomes through HES services, paying particular attention to building the capacity of local service providers and facilitating clinic-to-community referrals for PLHIV that can positively influence client adherence and retention.
In Mohale’s Hoek district, where the prevalence rate is 24%, LIFT has developed simple referral tools (mostly paper-based) to connect PLHIV from two rural facilities, Mpharane Clinic and Liphiring Clinic, to VSLAs near their homes. These VSLA were formed by some of the same community service providers who participated in the HES training LIFT delivered in 2013 as a result of what was learned. LIFT’s coordinating partner for referral work in the district, Centre for Impacting Lives (CIL), has alone helped form dozens of groups, many within the catchment areas of Mpharane and Liphiring. VSLA allow members to pool funds saved over time to distribute to members in need of urgent support and/or be paid out at the end of each savings cycle. Given widely acknowledged barriers to ART adherence, such as lack of resources for transport to facilities or limited food available to eat while taking the powerful ARV medications and bolster nutrition, these community-based savings outlets can augment PLHIV confidence, reduce stigma, and increase their ability to overcome other obstacles to adherence.
At Mpharane Clinic, Masekake Mpili Mkito is a Lay Counselor who has passionately advocated for and spread awareness on the clinic-to-VSLA referral work LIFT has helped facilitate. As a PLHIV herself, she recognizes the importance of ARV therapy, and how economic strengthening support via savings groups can help alleviate common stressors clients face when forced to choose how to prioritize limited resources to meet the needs of themselves and their families. In late 2015, Masekake was referred by another LIFT-trained Lay Counselor colleague at Mpharane to a VSLA near her home. Since then, her outlook has changed and she is excited about the future. Membership in the VSLAs has allowed her to borrow money that she needed to start a small business. Not much time has passed since her referral to the VSLA, but she says she has “no doubt” the linkage will improve her life in the long-run. In addition to economic prospects, she is already noticing positive health benefits of VSLA participation. It so happens that all members of her particular VSLA are PLHIV, so each meeting is not only used for savings and livelihood discussions, but also serves as a forum to support one another and share valuable advice on how to live positive lives with HIV. She says, “…we talk a lot about HIV related topics, since we are all HIV positive. Since joining the group I have changed my diet because of the tips I got there and my health has improved tremendously.” It is precisely these kinds of client-level changes that LIFT hopes to influence working with and through existing service providers to reach PLHIV and improve nutrition, ART adherence and retention at project sites. We have begun to collect longitudinal data to better analyze the effect of clinic-to-community referrals on health outcomes, and the Lesotho experience will help inform this understanding.
 UNAIDS. (2014). Lesotho. http://www.unaids.org/en/regionscountries/countries/lesotho
 UNAIDS. (2014). The Gap Report. http://www.unaids.org/sites/default/files/media_asset/UNAIDS_Gap_report_en.pdf
 Bemelmans M, Baert S, Goemaere E, Wilkinson L, Vandendyck M, van Cutsem G, Silva C, Perry S, Szumilin E, Gerstenhaber R, Kalenga L, Biot M, Ford N. (2014) Community supported models of care for people on HIV treatment in sub-Saharan Africa. Tropical Medicine & International Health 19; 8:968-977.