ENDLINE ASSESSMENT, REPORTING AND DOCUMENTATION OF THE INTEGRATED HIV/AIDS-NUTRITION PROJECT IN LESOTHO

1. BACKGROUND AND JUSTIFICATION

The people of Lesotho face multiple vulnerabilities, which include stunting (34%, MICS), chronic food insecurity and poverty (57% of the population live below the poverty line) and high levels of HIV infection (22.7% prevalence and the 2nd highest in the world- LePHIA,2020; LDHS,2014). Only 11% of children under the age of five meet their minimum acceptable diet, and 51% suffer from anaemia. In 2017, 1,786 (DHIS2) children were treated for severe acute malnutrition, while climate change consequences exacerbate chronic food insecurity: Lesotho either experiences long periods of droughts or the opposite, recent heavy rains led to flooding of crops. This affects at times up to a third of the population, deteriorating the livelihood base and resulting in income insecurity that disproportionately affects women. Infant and young child feeding (IYCF) practices remain suboptimal, and the lack of proper nutrition negatively affects adherence to anti-retroviral treatment (ART) against HIV/AIDS. Additionally, the 2017 UNICEF-supported Knowledge, Attitudes and Practices (KAP) study showed that children in Lesotho did not eat a diverse diet and their caregivers have limited knowledge on appropriate and quality feeding practices. The overall HIV prevalence in Lesotho among female adults of 15-49 years old stands at 27.9% according to the latest Lesotho Population-based HIV/AIDS Impact Assessment (LePHIA, 2020).

Among this group, HIV prevalence ranged from 3.9% for older adolescent girls aged 15-19 years (vs. 2.5% among boys the same age) to 46.5% for women aged 40-44 years (vs. 37.2% among men the same age). Based on LePHIA 2020 data, HIV prevalence was consistently higher among women than men in each 5-year age group from ages 15-19 years through 60-64 years. Additionally, adolescent girls aged 15-24 years are an immediate concern due to high levels of new HIV infections with a 1.7% incidence, which is 2.5 times higher than among adolescent boys 15-24 (LePHIA, 2017). New HIV infections in children 0-14 decreased by 22.5% since 2019, but the reduction of new infections among adolescents is lagging (Lesotho Spectrum Modelling Estimates, 2020). While Lesotho has 96% PMTCT coverage and 5.98% final transmission rate (Lesotho Spectrum Modelling Estimates, 2020), the sources of new paediatric infections stem from the quality of the programme and seroconversion during pregnancy and breastfeeding. Better adherence to national protocols that encourage exclusive breastfeeding together with ART adherence would help to ensure that infants who are born free of HIV remain HIV/AIDS free throughout the breastfeeding period. COVID-19 has also impacted the gains made in the last years, especially in primary prevention for adolescents and young people.

The synergy between malnutrition/HIV/AIDS and poverty is co-related in Lesotho. HIV causes immune impairment leading to malnutrition, which in turn leads to further immune deficiency and contributes to the rapid progression of HIV infection to AIDS, therefore creating a harmful cycle of HIV/AIDS, malnutrition, and poverty. Children and adults with HIV may have even less access to food because of stigma or a decreased ability to provide food for themselves. Stigma may lead to job loss or being cast out from the shelter of family or community. Severe illness may further result in economic instability and/or food insecurity. A malnourished child after acquiring HIV is likely to progress faster to AIDS because their body would be too weak to fight infection, whereas a well-nourished person can fight the illness better. It has been proven that good nutrition increases resistance to infection and disease, improves energy, and thus makes a person stronger and more productive, thus reducing the cycle of poverty. A child living with HIV who is not adherent to antiretroviral treatment or is not virally supressed.

1.1 PROGRAMME BACKGROUND AND OBJECTIVES

The integrated nutrition and HIV/AIDS programme started in September 2019 and was implemented in two countries: Eswatini and Lesotho. The Lesotho project was designed to improve the health and nutrition status of women and children, especially those affected and infected by HIV/AIDS. This project addresses the national plans and efforts to achieve Lesotho#s development priorities as stated in the NSDP II, the Agenda 2063 for Africa, and the Sustainable Development Goals, especially SDGs 2, 3, and 5. The project also aligns with the Reproductive Maternal, Neo-natal, Child and Adolescent Health and Nutrition Strategy (RMNCAH) 2021/2022 - 2025/2026, with the Food and Nutrition Strategy and Costed Action Plan of 2019 2023, with the Lesotho National HIV/AIDS Strategic Plan 2018/19  2022/23, and with the overarching National Health Strategic Plan (NHSP) 2017-2022. Moreover, the project contributed towards the Lesotho progress of eliminating mother to child transmission (eMTCT) of HIV/AIDS by 2020.

Moving forward, Lesotho is well positioned to reach the UNAIDS 95-95-95 targets by 2025 and to achieve the UNAIDS goal of ending the AIDS epidemic by 2030, as per the National HIV/AIDS Policy (2019). The project also has an equity component: targeting the most vulnerable households in priority districts identified by the National Information System for Social Assistance (NISSA http://www.socialdevelopment.gov.ls/nissa). As part of this project, health service providers were equipped with the skills to promote optimal feeding practices, prevent MTCT of HIV, support good ART adherence and give micronutrient supplements to pregnant women and children under five.

Additionally, communities were mobilized to overcome the structural barriers preventing women to optimally feed their children and support women to adhere to anti-retroviral treatment. Ultimately, the programme aimed to

1) reduce barriers to the use and access to nutrition and HIVHIV/AIDS services

2) strengthen health system for improved maternal and child health outcomes, and

3) enhance the quality of health services in 69 community councils in Lesotho.