II. Recommendations

Although the Know Your Status campaign was supposed to end in late 2007, the government of Lesotho has decided to integrate it into the Ministry of Health and Social Welfare and continue the campaign, as part of a broad scale up of HIV testing approaches, including the implementation of a problematic new mandatory testing policy for pregnant women in healthcare settings.[8]

It is very important that HIV testing be expanded to reach the entire population of Lesotho. However, for such efforts to be successful, greater attention to the principles of informed consent, confidentiality, linkages to services and support, accountability, and improved policy must be instituted. Going forward, the government of Lesotho and its partners should recognize that in order to ensure HIV testing services are a part of comprehensive prevention and treatment approach, they will need to secure the resources and implement the oversight necessary to expand quality HIV counseling and testing in a way that respects rights, reduces the vulnerability of those who test negative and protects the rights of those testing positive.

To the Government of Lesotho

·Provide counselors with additional training and guidance on informed consent and confidentiality. A particular concern should be addressing women and minors prevented from consenting to or declining tests, and providing training to address sero-discordant couples and testing and counseling of couples.

·Strengthen general preparation and support offered to KYS counselors. The training curriculum needs considerable revision; a way needs to be found to provide meaningful field training and to ensure adequate supervision without overburdening existing health structures; counselors must be provided with adequate tools, such as counseling check lists and ID cards, to consistently provide good services, and should be paid incentives as promised.

·Ensure linkages to HIV-related services. People should be referred to post test services whatever their test result. People who test negative must receive the knowledge and skills to avoid infection and be able to protect themselves.  Those who test positive must have effective access to care and treatment, including to TB services. Treatment should become available at all healthcare centers as soon as possible.

·Put in place workable supervision and quality control mechanisms that are capable of identifying problems in a timely fashion and allow redress for individuals who feel that their rights have been violated.

·As a matter or priority, put in place independent oversight mechanisms to collect any potential complaints about problems with confidentiality, consent, linkages to other health services, and abuse based on HIV status. Civil society groups should play a key role in these mechanisms.

·Adopt laws and policies that protect people who test positive against stigma and discrimination and enable people who are negative to remain so. In particular, laws recognizing women and children's right to inheritance and laws against domestic violence, property grabbing and discrimination in all work places, need to be adopted.

·Ensure that no mandatory testing takes place in antenatal settings. Testing of pregnant women must include specific consent to be tested.

To WHO/UNAIDS

·As more and more countries in sub-Saharan Africa and other parts of the world experiment with different types of community-based HIV counseling and testing programs, there is a critical need for WHO and UNAIDS to learn from the experience of the Lesotho KYS program and to provide countries with detailed guidance on how such programs can be implemented while respecting and protecting human rights based on the recommendations addressed here to the government of Lesotho.

·In addition to providing guidance on community-based testing models, support the development of multiple venues of HIV testing to ensure that people can choose those services that they feel will best protect their rights.

To Donors to HIV Counseling and Testing Programs

·Support a review of various community-based HIV counseling and testing initiatives in sub-Saharan Africa and elsewhere in order to identify both best and worst practices and develop the evidence base for community-based testing programs.