IPPF provides comprehensive sexual and reproductive health care to clients around the world. HIV testing, prevention, and treatment services are essential parts of our integrated sexual and reproductive health care package. To expand the choices individuals have to protect themselves from HIV, IPPF is excited to announce a special program to provide the newest methods of HIV prevention - injectable PrEP (a 2-monthly injection of cabotegravir-LA) and the vaginal ring (a monthly vaginal ring of dapivirine), as well as expanding where oral PrEP is offered. This program is being launched through a consortium of IPPF Member Associations called the Consortium to Advance Access to new HIV Prevention Products (CAAPP) - led by Family Planning Association of India, and including the Family Life Association of Eswatini, Lesotho Planned Parenthood Association, Family Planning Association of Malawi, Federation of Reproductive Health Associations, Malaysia, Family Planning Association of Nepal, and Planned Parenthood Association of Thailand. We hope this program will increase access to the number of ways people can protect themselves from HIV, supporting individual's choice to find an HIV prevention method that works for them.

Lesotho, a country situated in Southern Africa and landlocked by the Republic of South Africa, has an estimated total population of 2.1 million people. The small country is still heavily affected by HIV and AIDS, with high prevalence rates of 24.3% among women aged 15-49, and 14.2% among men in the same age bracket. The Lesotho government, in partnership with various non-governmental organizations, continues to address these alarming rates, including among adolescents and youth. One of the government’s key partners in the country is IPPF’s Member Association in Lesotho, Lesotho Planned Parenthood Association (LPPA). One of LPPA’s strategy aimed at increasing HIV linkage and retention in care and treatment among adolescents and young people living with HIV, is through an initiative known as the ‘Red-Carpet model’. The initiative, started in May 2023, is being piloted in LPPA’s youth clinic located in the capital city, Maseru. The ‘Red-Carpet model’ is aimed at providing adolescents and young people with a VIP experience as they access quality youth-friendly services at the facility. The model fast tracks services and reduces barriers for adolescents to access and utilize integrated HIV/SRH services. We had a chat with Ms. Mamojela Koneshe, LPPA’s Executive Director, who sheds more light on this initiative. How exactly does the ‘Red-Carpet’ model work? The model serves all adolescents and young people who visit the clinic, regardless of if they are first time or returning clients. For the new clients, they first report to the reception area upon arrival at the clinic. They are then referred to the waiting area where an LPPA Youth Ambassador gives them information about the model, how it works and its benefits. Youth Ambassadors are young people seconded to LPPA clinics by one of our partner organizations - Elizabeth Glaser Paediatric AIDS Foundation (EGPAF). Their duties include ensuring that adolescents in the clinic are linked to appropriate HIV prevention methods and treatment. They also hold scheduled peer support groups, and in collaboration with the Youth Nurse, link vulnerable youth to various organisations depending on their needs –for example linking sexual and gender-based violence survivors to shelters. The Youth Ambassadors also ensure that red carpet model is well implemented. While at the waiting area, the Youth Ambassador gives the adolescent or young client access to free wi-fi, which enables them to access the internet. After this, the client is enrolled in the model and given a VIP card. When their turn arrives, the Youth Ambassador escorts them to the relevant consultation or counselling room depending on the service they need. The expected time spent in the facility by the young person is 45minutes. This is the maximum time expected to be spent by young people while accessing services and was informed by the various services that young people access in our facility. Telephone follow-up interviews are then done with the clients on a weekly basis. On their return visit, upon arrival at the facility, adolescents report to the reception where they present the VIP card they were given at their first visit. They are then referred to the waiting area where once again, the Youth Ambassador gives them a free wi-fi voucher and links them to the appropriate service. Similarly, the expected time spent in the facility is 45minutes. Why is the provision of free internet to adolescents and youth at the clinic important? This is because it enables young people to access a vast amount of health information online. By connecting to the internet, they search for health-related information. It also gives them access to educational resources that can help them make informed decisions about their health. Going online also helps them to connect with their peers within established peer support groups. In addition, most of our clients are students at colleges, universities, and other learning institutions, so facilitating their free internet access helps them to continue studying and researching while waiting for services. They like this since they don’t have to use their own internet bundles, which can be quite expensive for them.

“I saw this challenge when children are having children and they're having a number of children at a very young age,” says 37-year-old Matiisetso Sefako, after emerging from the Lesotho Planned Parenthood Association (LPPA) tent in Mokhethoaneng village, an hour drive from the capital Maseru. “For them to be engaged in family planning, it would really help them.” The mother of two lives just outside the village and says she’s become something of a community activist on the issue of early child marriage and the need for family planning. After she receives services, she lingers for an hour, speaking with young women and teenage girls who are looking over at the LPPA mobile clinic with interest.    She herself was a 19-year-old mother and has been using contraceptives for nearly 20 years. Then, it was harder to come by and she would often have to travel at her own cost. Now, she comes regularly when LPPA makes the monthly visit to her village.  And she’s done quite a lot on this to advise people to try and convince them to come and access such services, she says.  “The only problem I encounter is that the biggest challenge within the village is that there is a high rate of teenage pregnancy. I try to convince them this tent will help.”  This is her fourth visit to the LPPA outreach to receive services herself. Her only wish? “That these services be here every day,” she says, explaining that there is a deeply-felt need in her community and her hope is that she can refer more young women to follow up and receive the same monthly services she benefits from.  

When Raphel Marafan Kori’s husband died in 2001, she was left to fend for herself, in a largely patriarchal society. Now 45-years-old, she keeps busy and earns an income as a peer educator in Tsenekeng village in Lesotho’s Semonkong region.  She goes door to door to counsel her neighbors and residents of the village in family planning options available. She’s been doing it for nine months and visibly brightens when she starts talking about the work. "I introduce myself, after that I explain to the people the services that we provide, the importance of the choices that we can make about contraceptives."  She was appointed by the village chief, Makholu Mahao, to participate in a training provided by LPPA in the capital, Maseru and soon after, dove into her fieldwork. Some people immediately understand and welcome the offerings, she says, while others take some time.  Protection & permission  Now nine months into the work, she says the biggest issue facing her community is “that adolescents still need consent from the parents. And the parents seem to have a problem with that because in a way, [they think] it is allowing them, giving them the freedom to indulge in sex.”  “Another way I can explain [is to] mention  HIV testing here and to remind [parents] it's not only they're getting protection but also for them to help them plan for future."   Going door to door Occasionally she’ll hold community gatherings, but mostly she has these conversations door to door. “I’m working very hard to make sure the children also engage in this for the future. It’s a challenge,” she admits. She herself comes to the mobile outreach post for family planning services, something she says helps break the ice when she is out in the community talking about family planning. She tells them she uses the pill because she is allergic to the injectable option offered here.  “I get to talk to people because I can counsel them on HIV and AIDS daily to make them understand that just because you have HIV it's not the end of the world but you need to take your medication properly and life continues,” she explains proudly, sitting a few meters away from the She Decides tent with a line of women outside. Overall, she says she has benefitted as much from her work as the beneficiaries. “I engage with people. I also learned a lot, it educated me especially on the protection side because even myself before I was not aware of such information but now I've learned and I can give other people this information.” 

“I was 18 when I married. But back then that was old!” 76-year-old Makholu Mahao laughs as she goes on to list her nine children – 4 boys, 5 girls including twins.  “At the time that I was married, if I knew about contraceptives, I wouldn’t have had so many children,” she insists.  Her tone becomes forceful and serious when she shifts to subjects like teenage pregnancy and childhood marriage, both ills that are prevalent in her village in the Semonkong region, known as Tsenekeng Hamojalefa.  The village sits atop a rocky hillside, most easily accessible by horse or donkey, and 114 kilometres from the capital, Maseru. She is the village chief now, a post she took up when her husband, the former chief, died.  And to her, “the big challenges are teenage pregnancy and early marriage. We’re seeing the difficulty in labor, children dying in labor, and young mothers dying in early labor. Those are the main things I need assistance with,” she explains to staff from Lesotho Planned Parenthood Association (LLPA), on a field visit to LPPA’s mobile clinic down the hill from Makholu’s home.  More than family planning “How can we stop this problem,” she asks her visitors.  Underage girls “marry at a young age, they don’t know what marriage is. They bear children and bear children and have problems, like death or infant death,” she reiterates. And it’s not just family planning that benefits the residents of her village. 16 villages ring the hillsides around the mobile outreach post, set up today to offer family planning, counseling, and HIV testing.  Before the arrival of LPPA on a monthly basis, “we were not receiving any other services other than the two clinics,” she explains, describing clinics approximately 40 km from her village. She adds, “We would leave early in the morning to get there at 9 or 10 to get the services. It was very congested so we would leave and get back here without getting any services.” Encouraging young people When it comes to combatting stigma in a patriarchal society, this great grandmother says some couples do go together for services or at least are in agreement about pursuing services. Still, “men cannot go with the women,” she explains. Throughout the day, men and women gather in separate groups outside the LPPA tents to receive consultations separately.  She sends a strong message by giving her OK for underage single women to seek family planning services. “It is acceptable that [minors] can get it [services], single or not,” she says. “At the end of the day, it’s protection for early pregnancy. The elderly – like me – don’t usually agree with that. But the [minors] will go on their own, however they can. I support that.”    

Bolelwa Falten in based in Losotho’s capital, Maseru, and has been working as a HIV counsellor for the better part of a decade, bouncing from different organizations depending on where the funding goes. Before she joined, IPPF nine months ago, 40-year-old Bolelwa worked with PSI Losotho. Now, she runs the “North team” as part of LPPA’s outreach program.  She handles five different outreach posts and today, she is running the HIV testing clinic at one site.  Bolelwa proudly takes us through the full range of tests and counseling services they offer there, taking particular pride in explaining how she follows up patients who test positive. She knows the beneficiaries appreciate the work – it’s something she sees every time she does an outreach day.  “They no longer need transport money, time to get to the clinic. Our being here is actually bringing the service to where they are and where they need it,” she says. But quickly, she follows up, noting that in general, HIV and STI mobile healthcare services have been hit-hard by funding cuts in recent years.

"This is a relief. I'm feeling very happy now that services have been brought,” 34-year-old Makamohelo Tlali, says, smiling outside the Lesotho Planned Parenthood Association (LPPA) tent on the hillside of Hamoshati village in Lesotho. Makamohelo is a relatively new beneficiary of family planning services offered monthly at a post near her village. This is her second visit. She walks over 30 minutes each way but says that’s by far the best option for her.  "I feel happy that services are here, for free. When I accessed them before it would take transport costs to get to the place."  In the past, it would cost her 40 rand for taxis to the closest clinic, plus the additional cost of family planning services.      Makamohelo first heard about these offerings from a peer mobilizer going door to door in her village.  “I met her along the way and discussed the way I can access family planning services. They’re scarce this side. And she told me on a specific date there would be LPPA people offering services." “Now here I am,” she says, laughing.  She takes advantage of the free HIV testing offered here as well and says she is hopeful the family planning will be maintained, mentioning that other NGOs have come and gone over the course of several years. For her and her husband, family planning is openly discussed in the household and important for the health of their current family. They have three children, 2 girls and a boy.  “Three is enough! My husband has no problem with me accessing family planning here,” she explains, adding that her husband relies on piecemeal jobs while she farms to feed the family. 

Mafusi Nthebe sits under a tree at midday in Malumeng village, about an hour drive from Lesotho’s capital Maseru. She’s laughing and joking with her friends, teenagers and 20-somethings, as her three-year-old son climbs on her back.  “It was just one of those mistaken situations that I fell pregnant [as a teenager],” she explains, talking about her family life.  “How can we stop this problem?”  Today, the 22-year-old lives with her grandmother. She’s a single mother and has no income and her grandmother’s elderly social security check from Lesotho’s government is the only financial support she has.  “It seems or looks normal here,” she says, of her friends, many of whom were also teenage mothers.  Here and further into Lesotho’s rural communities – like in the Semonkong region – it is indeed normal, says 76-year-old Makholu Mahao.  She herself was married at age 18 but then, “that was old,” she laughs. Today she is the chief of Tsenekeng village, a post that was passed on to her only when her husband died. Lesotho is still largely a patriarchal society, where a large number of women and girls are struggling to gain access to life-saving sexual and reproductive healthcare and rights. Makholu is visibly upset about these factors as she speaks about the situation for girls in her village, namely, she says, the alarmingly high rate of teen pregnancies.  “How can we stop this problem?” she says, “Children are dying in labour, [young] mothers are dying in early labor. They bear children, they get problems…Children [are] getting married!” During a meeting between community leaders in Semenkong district and LPPA staff, the leaders echoed these concerns, particularly noting that despite progress made under the DREAMS program, which targeted adolescent and young women in order to provide reproductive health and family planning services, when the program was halted by the introduction of the global gag rule, young women and girls suffered immediately.    Rebuilding trust Mahopalang Hlephe, a 54-year-old woman, spoke up first during the meeting.   “Specifically, in my area during this break [in family planning services], we suffered a lot. LPPA [had] provided services. There were alarming rates of unintended pregnancy. Being here, leaving tomorrow...the break is really disturbing the community and they are losing interest and trust in organizations.” Across the table from her, Matooase Rammalei, 30, chimed in. In Semonkong like in much of rural Lesotho, terrain is difficult and transport to clinics in neighboring villages is costly. When the monthly family planning and HIV testing posts temporarily stopped – before the launch of the She Decides project – women had nowhere to go for follow-up on family planning methods they were using.  “This has been a very serious issue,” he says. “One example were those who were using injectable [birth control.] They never had anywhere to refer uncommon symptoms [or] side effects. There was nobody to address that.”  While there is no specific data to track a possible surge in the rate of unintended pregnancies, teen pregnancies, or HIV in the two districts that experienced an interruption in services due to the GGR, it is clear that community leaders across these districts saw a distressing impact firsthand. These days, the same districts and communities have received family planning and HIV-testing services for nearly a year, thanks to the Belgian-funded She Decides program. Community buy-in and awareness of these services is increasing once again. Village chiefs largely support the program and community leaders like those at the meeting clearly do as well. They say they only hope that funding will remain to continue the program and to increase the accessibility of these services in their villages. 

“We believe that we are just there for reproduction. We are there to make men happy”.  These are just a few blunt examples Lesotho Planned Parenthood Association’s (LPPA) program director, Makatleho Mphana gives to explain what LPPA is up against. “And men take advantage of that” she adds. Deeply engrained cultural and harmful, patriarchal societal norms are still common in the communities that LPPA serves.  To help change attitudes towards harmful social norms, LPPA has spent years in the field operating mobile outreach posts, focused on bringing family planning, reproductive health services, and HIV testing to hard-to-reach villages across nearly unnavigable terrain in Lesotho, known as the “mountain kingdom.” The women and men they serve “are hard to reach, vulnerable,” she explains, adding many rural villages lack access to full service health clinics and people have to travel long distances to reach them.  The GGR impact on the ground The program to bring family planning and HIV testing services to these populations – known as DREAMS - was a joint effort between Population Services International (PSI) Lesotho and LPPA. It was meant to be a two-year outreach project aimed at adolescent girls and young women, in order to reduce the rate of unintended pregnancies and HIV transmission. But a year into the program, the rug was pulled out from under Makatleho’s LPPA staff, bringing the DREAMS program to an unexpected halt. Upon the passage of The Mexico City Policy – more commonly known as the Global Gag Rule (GGR) - in the U.S, LPPA was no longer able to receive U.S President’s Emergency Plan for AIDS Relief (PEPFAR) funds to support the program. GGR essentially denies American funding of organizations like IPPF and LPPA, if they use non-US funds to provide abortion care.  The passing of the law was a massive blow in Lesotho: cutting off nearly $400,000 of funding and denied women and girls in remote, and tough-to-access villages with critical reproductive health and HIV testing services.  Lesotho, with a population of 2.2 million, has one of the highest maternal mortality rates in Southern Africa, driven by factors like poor access to quality healthcare, unsafe abortions, unmet need for contraceptives, and high rates of adolescent pregnancies. According to LPPA, there was a 42% drop in services they provided across Lesotho from 2016 to 2017, much of which was attributable to the passing of GGR in the U.S.  “I tell people when [PSI] shared the news, I shed a tear,” Makatleho Mphana recounts. “I was thinking of the number of service providers that we had engaged to implement this project,” she says, noting that in addition to the services pulled from rural beneficiaries, many newly trained staff – from nurses to community mobilizers –  lost their jobs."  “Suddenly to these people we were telling them we shall no longer be coming…we believe that has had quite a big impact. Probably some fell pregnant right away, maybe there were people maybe who were thinking I was going to take the next step and know my HIV status and they were never able to do that…The impact was pretty bad.” Rebuilding trust Bolelwa Falten, 40, an HIV-testing-services counselor in Berea – one of the districts where the DREAMS program came to an early stop – saw this firsthand. Today, with the support of the Belgian-government-funded She Decides program, she is back in the field, staffing one of the outreach posts in a small village in the Berea district.  While the program has been up and running again for nearly a year, she still feels the impact of the interruption of service-provision. “It takes a while to get people to come back [when we start up services again]. When we got back into the field, people complain that once we start trusting you and say we’re going to work with you, you disappear,” she explains, adding. “But we try to explain we rely on donor funding.” Mobile outreach posts like this one are now part of the She Decides program, an initiative launched when LPPA received just under $400,000 of emergency funds from the government of Belgium in order to fill the gap left by the loss of funds due to the GGR. Funds are now allocated to five clinics across Maseru, the capital, and to mobile outreach posts in two rural districts of Lesotho, including the ones at which Bolelwa works, in the “north district” of Botha-Bothe as well as in the Semonkong region.  Reaching communities Raphel Marafan Kori, 45, is a member of the LPPA mobile clinic team in Tsenekeng village, in Semonkong, about 114 kilometres outside of the capital. She is happily working in the field as peer educator, going door to door to tell those in her village and neighboring villages about the options available at LPPA’s monthly mobile outreach posts. A widow, the job helps her support her two daughters and she proudly shares that she also receives family planning services at this monthly post.  But mostly, she says enjoys engaging with people, learning from the outreach training and taking that new information to those in her community. “It educated me especially on the protection side because even…I was not aware of such information…Now I've learned and I can give other people this information,” she says, smiling. “You get to talk to people…I can counsel them on HIV daily to make them understand that just because you have HIV it's not the end of the world… life continues.”