THE IMPACT OF HIV/AIDS AS A DISASTER ON THE POPULATION
STRUCTURE OF LESOTHO
By
Johanes Amate Belle
A mini dissertation submitted in partial fulfilment for the award of the Master’s Degree in
Disaster Management
in the
Faculty of Natural and Agricultural Sciences
(Disaster Management Training and Education Centre for Africa)
at the
University of the Free State
Supervisor: Dr S.B. Ferriera
Bloemfontein
January 2010
ACKNOWLEDGEMENT
I would like to begin by thanking the Almighty Lord for giving me life, strength and the
knowledge to carry out this research. I am deeply indebted to so many people and institutions
that helped me in one way or the other to be able to go through my research. I will be unable to
mention all the names here due to lack of space but you are all listed in my heart.
I would like to heartily thank my supervisor, Dr. Sandra Ferreira under whose mentorship I had
the opportunity to learn a lot. She really rekindled the spirit of hard work and determination in
me and above all held me by the hand through the path of conducting research. My relation with
Dr. Sandra turned to be both on family and academic basis. Thank you Dr and May God richly
bless you.
I would also like to thank Mr Jordaan Andries who to me is like a father and an overall
supervisor to all the DiMTEC students. I am very proud to be a product from DiMTEC. I could
not have realised this project without help from people like Mr Moerane Palesane, Mr Nkopane
and the Bureau of Statistics (BOS) for the assistance that I received from them.
I would also like to thank the Lesotho Ministry of Health and Social Welfare (MOHSW) for the
ethical clearance and the documents I got from them on HIV/AIDS. I acknowledge the
encouragement and help I received from Sr Catherine Ntoloane (Principal of Holy Names High
School, Bela-Bela) and the Cameroonian community in Lesotho especially, Dr Tanga Pius and
Dr Beatrice Ilongo. I also wish to thank Mr Kamara Ismeal for his help and contribution to my
studies at DiMTEC. Mr Rampokanyo John, Mr Nkwelle Bradon and Mr Sone Ngulle are not
forgotten
Last but not the least I would like to thank my family especially Mr Belle Michael for all he did
for my education.
II
DEDICATION
This work is dedicated to my lovely and supportive wife (Mrs Belle Gladys), my son
(AmateBelle Fidelis) and my daughter (AmateBelle Rahael) for the sacrifices they made and the
support they gave me during my studies. And to God be the glory!
III
ABSTRACT
This mini dissertation was carried out as part of the requirements for the award of the master‟s
degree in disaster management at the University of the Free State. The aim of the research was to
investigate the impact of HIV/AIDS disaster on the population structure of Lesotho with more
attention from when the first HIV case was reported in 1986 to when the last national population
census was conducted in 2006. HIV/AIDS is a serious problem in Lesotho. With an adult HIV
prevalence rate of 23.2%, Lesotho is ranked the third highest affected country in the world.
Within a period of three years (2003 to 2006), the total population of Lesotho decreased from 2.2
million people to 1.8 million people. Without any civil war in the country which could cause
such a rapid drop in population, therefore one of the main causes for the population decrease was
the effect of HIV/AIDS pandemic. The pandemic did not only affect the total population but the
age and sex composition of the population of Lesotho as well. The study was done from a
disaster management perspective and the progression of vulnerability (PAR) model was used as
the main conceptual framework. By using the PAR model, the researcher was able to explore and
explain the economic, social, cultural, environmental and even political weaknesses in Lesotho
that the HIV/AIDS pandemic exploited to overwhelm the coping capacity/ resilience in Lesotho
leading to the declaration of a national HIV/AIDS disaster in 2000. To assess the damage that the
HIV/AIDS disaster had on the population trajectory of Lesotho, the Demographic Transition
model was explored in the research. An in-depth literature review was carried out using (in most
cases very resent) international, regional and national sources. The literature review first looked
at the background of HIV/AIDS, followed by an exploration of the global situation. The
HIV/AIDS situation in Africa was examined with much attention on southern Africa sub region
which happens to be the epicentre of the HIV/AIDS pandemic. Lastly the literature review was
funnelled down to the HIV/AIDS situation in the Kingdom of Lesotho, which was the focus of
the research. Throughout the literature review, attention was paid on HIV/AIDS parameters such
as the prevalence rate, the morbidity and mortality rates, AIDS orphans and the age and sex
differential impact of HIV/AIDS. The researcher used a hybrid of both quantitative and
qualitative research methods but with more inclination towards quantitative approach.
The empirical study was based on questionnaires that were completed by 116 medical personnel
in Lesotho. The respondents were recruited using a simple random sampling and seven out of ten
IV
districts were covered in the sampling. The recruitment of medical personnel was guided by the
fact that they deal with HIV/AIDS cases almost on daily basis. Besides the questionnaires, the
researcher also interviewed the chief executive officer (CEO) and the public relation and
communication officer of the Lesotho Disaster Management Authority (DMA) on 02 September
2009. The interview enabled the researcher to have a better insight on the role DMA played or is
playing in the management of HIV/AIDS as a disaster in Lesotho. Part of the empirical study
was done using Secondary Data Analysis (SDA). The SDA examined in the research were the
1976, 1986, 1996 and 2006 national population census data. From these population censuses, the
researcher was able to identify the changes in the population structure of Lesotho within the
HIV/AIDS era. In order to estimate which of these changes could be attributed to the impact of
HIV/AIDS, the researcher used data from HIV/AIDS monitoring institutions like the UNAIDS,
the Lesotho Ministry of Health and Social Welfare (MOHSW), the Lesotho National AIDS
Commission (NAC), the World Health Organisation (WHO) as well as data from the empirical
study. The results were analysed and interpreted using simple descriptive statistical techniques.
The conclusions and recommendations in this research were based on both the literature review
and the empirical investigations that were carried out by the researcher. The key findings from
the research include:
 HIV/AIDS has an impact on all the components of the population structure of Lesotho
but the highest impact is the rapid increase in morbidity and mortality rates
 Demographers and population geographers would need to redraw the population pyramid
of Lesotho and other developing countries that are heavily affected by HIV/AIDS
 The number of AIDS orphans and therefore that of vulnerable children continue to rise in
Lesotho. This very vulnerable group of the population may have unmet psycho-social and
other needs that warrant further investigation
 HIV/AIDS disaster presently has a different management set up from other disasters in
Lesotho
It is however recommended that further research be carried out on the impact of HIV/AIDS on
the population structure of Lesotho with a larger population sample and involving all the ten
districts. The current ongoing Demographic and Health Survey (DHS) could prove very valuable
for such a research. Other research gaps exist such as to investigate the socio-economic and
V
psycho-social impact of HIV/AIDS especially on children in Lesotho as well as ways to improve
on positive behavioural changes among adults in Lesotho with regards to HIV/AIDS.
KEY WORDS
Disaster
Disaster management
HIV/AIDS
Lesotho
Population structure
Vulnerability
VI
DECLARATION BY LINGUIST
VII
DECLARATION BY THE RESEARCHER
I Johanes Amate Belle hereby declare that all work included in this report is my own work; that
none of the work included in this report is a copy of the work of any other current or former
candidate or a group of candidates for this research or any similar research; and that all work and
other sources (literature or empirical) that were consulted and used for completing this report
have been properly and completely acknowledged according to generally accepted principles of
referencing
Signature: ………………………………
VIII
TABLE OF CONTENTS
PAGE
ACKNOWLEDGEMENT………………………………………………... II
DEDICATION……………………………………………………………. III
ABSTRACT……………………………………………………………….. IV
KEY WORDS……………………………………………………………... VI
DECLARATION BY LINGUIST……………………………………….. VII
DECLARATION BY THE RESEARCHER……………………………. VIII
LIST OF FIURES……………………………………………………….... XIII
LIST OF TABLES……………………………………………………..…. XIV
LIST OF ACRONYMS………………………………………………..…. XV
CHAPTER ONE: METHODOLOGICAL ORIENTATION………..… 1
1.1 INTRODUCTION …………………………………………………….. 1
1.2 RATIONALE FOR THE CHOICE OF THE TOPIC………………….. 2
1.3 SIGNIFICANCE OF THERESEARCH……………………………….. 3
1.4 RESEARCH STATEMENT, RESEARCH PROBLEM AND
RESEARCH HYPOTHESIS…………………………………………... 4
1.4.1 Research statement……………………………………………... 4
1.4.2 The research problem…………………………………………... 5
1.4.3 Research questions……………………………………………… 5
1.4.4 Hypotheses……………………………………………………….6
1.5 THE AIM, GOAL AND OBJECTIVES OF THE RESEARCH……..... 6
1.5.1 Aim of the research……………………………………………... 7
1.5.2 Goals of the research…………………………………………… 7
1.5.3 The research objectives………………………………………… 8
1.6 THE RESEARCH DESIGN………………………………………….... 9
1.7 THE RESEARCH METHODOLOGY………………………………… 10
1.7.1 Literature study………………………………………………… 10
1.7.2 Empirical investigation…………………………………………. 10
1.8 DEARCATION OF THE INVESTIGATION…………………………. 12
IX
1.9 DEFINITION OF CONCEPTS……………………………………….. 13
1.9.1 Birth rate or fertility rate…………………………………….. 13
1.9.2 Death rate or mortality rate…………………………………... 13
1.9.3 Disaster…………………………………………………………. 14
1.9.4 Disaster management…………………………………………....14
1.9.5 HIV/AIDS……………………………………………………….. 16
1.9.6 Lesotho………………………………………….……………….. 16
1.9.7 Migration…………………………………….………………….. 16
1.9.8 Population pyramid………………………………….…………. 17
1.9.9 Population structure…………………………………….……… 17
1.9.10 Resilience………………………………………………………..18
1.9.11 Vulnerability………………………………………………….. 18
1.10 COMPOSITION OF THE RESEARCH REPORT…………………... 18
1.11 SUMMARY………………………………………………………....... 19
CHAPTER TWO: AN INTEGRATED CONCEPTUAL
FRAMEWORK…………………………………..… 20
2.1 INTRODUCTION……………………………………………………... 20
2.2 THE PRESSURE AND RELEASE (PAR) MODEL………………..… 21
2.2.1 The root or underlying causes……………………………... 22
2.2.2 The dynamic pressures……………………………………... 29
2.2.3 The unsafe conditions…………………………………….… 35
2.3 LINKING THE PAR MODEL, DISASTER RISK REDUCTION
AND HIV/AIDS IN LESOTHO……………………………………..… 37
2.3.1 The risk equation and HIV/AIDS in Lesotho…………...… 38
2.4 THE DEMOGRAPHIC TRANSITION (DMT) MODEL…………..… 39
2.4.1 The precepts of the DMT………………………………...… 39
2.4.2 The application of the DMT to the impact of HIV/AIDS
in Lesotho……………………………………………………42
2.5 SUMMARY……………………………………………………………. 43
X
CHAPTER THREE: LITERATURE REVIEW ON THE
PHENOMENON OF HIV/AIDS………………. 44
3.1 INTRODUCTION…………………………………………………...… 44
3.2 A BRIEF HISTORICAL BACKGROUND OF HIV/AIDS…………… 45
3.3 HIV/AIDS: THE GLOBAL SITUATION…………………………...…46
3.3.1 The global HIV prevalence rate………………………….....46
3.3.2 The global AIDS deaths and the effects on life
expectancy………………………………………………..… 49
3.4 HIV/AIDS SITUATION IN LESOTHO………………………………. 52
3.4.1 HIV prevalence rate in Lesotho……………………………. 52
3.4.2 The impact of HIV/AIDS on mortality and life
expectancy in Lesotho…………………………………...… 55
3.4.3 The impact of HIV/AIDS on fertility rate in Lesotho…..…57
3.4.4 The impact of HIV/AIDS on migration………………….... 58
3.4.5 HIV/AIDS orphans and vulnerable children in Lesotho… 60
3.4.6 The effects of HIV/AIDS on the economy of Lesotho….…. 62
3.5 SUMMARY………………………………………………………….… 63
CHAPTER FOUR: EMPIRICAL STUDY AND DATA ANALYSIS… 65
4.1 INTRODUCTION……………………………………………………... 65
4.2 RESEARCH DESIGN……………………………………………….… 65
4.3 RESEARCH METHODOLOGY……………………………………… 66
4.3.1 Methodology for literature study………………………….. 66
4.3.2 Methodology for empirical investigation………………….. 67
4.4 DATA ANALYSIS AND DICUSSION……………………………..… 72
4.4.1 Secondary Data Analysis (SDA) and presentation
of results……………………………………………………... 72
4.4.2 Primary data analysis and presentation of results……….. 79
4.5 SUMMARY………………………………………………………….… 91
XI
CHAPTER FIVE: CONCLUSIONS AND RECOMMENDATIONS… 93
5.1 INTRODUCTION………………………………………………….….. 93
5.2 RESEARCH PROBLEM, RESEARCH HYPOTHESIS AND THE
AIM OF THE RESEARCH……………………………………….…… 94
5.3 CONCLUSIONS………………………………………………….…… 94
5.3.1 The PAR model as a conceptual framework…………….... 94
5.3.2 The research problem………………………………………. 95
5.4 RECOMMENDATIONS………………………………………………. 98
5.4.1 Practice…………………………………………………….... 98
5.4.2 Theory……………………………………………………..… 99
5.4.3 Training, education and research………………………..…101
5.4.4 Policies……………………………………………………..… 102
5.5 CONCLUDING REMARKS………………………………………..…. 103
LIST OF REFERENCES………………………………………………....105
APPENDIX A: ETHICAL CLARANCE CERTIFICATE……………..… 113
APPENDIX B: THE POPULATION OF LESOTHO IN 1976, 1986,
1996 AND 2006……………………………………..…… 114
APPENDIX C: QUESTIONNAIRE FOR EMPIRICAL
INVESTIGATION………………………………….…… 117
APPENDIX D: THE PROGRESSION OF SAFETY MODEL…………... 124
XII
LIST OF FIGURES
Page
Figure 1.1
The administrative map of Lesotho…………………………1
Figure 1.2
The disaster management continuum……………………… 15
Figure 2.1
The pressure and release (PAR) model…………………… 22
Figure 2.2
The demographic transition model………………………… 41
Figure 3.1
The global number of people living with HIV (1990-2007)..47
Figure 3.2
The global percentage of adults (15+) living with HIV
who are female (1990-
Figure 3.3
2007)…………………………….. 49
The estimated global number of adults and children deaths
due to AIDS(1990-2007)…………………………………... 50
Figure 3.4
Rural/urban HIV prevalence rate over time in Lesotho
(1991-2007)………………………………………………...53
Figure 3.5
HIV prevalence rate by district in Lesotho in 2007………... 54
Figure 3.6
Estimated number of AIDS orphans in Lesotho
(1994-2012)…………………………………………………62
Figure 4.1
HIV prevalence rate, new infections and AIDS deaths
in Lesotho (1990-2007)……………………………………..75
Figure 4.2
The population pyramids of Lesotho for
1976, 1986, 1996 and 2006………………………………... 76
Figure 4.3
HIV/AIDS as a cause of death in Lesotho from
the empirical study………………………………………… 83
Figure 4.4
Rating of AIDS related deaths in Lesotho…………………. 85
Figure 4.5
General trend in HIV/AIDS in Lesotho from the
empirical study……………………………………………... 85
Figure 4.6
Antenatal testing for HIV from the empirical study…………86
Figure 4.7
General trend in births in Lesotho from the
empirical study…………………………………………….. 87
Figure 4.8
Degree of risk of HIV from MTCT according to the
empirical study……………………………………………... 88
XIII
LIST OF TABLES
Tables 3.1
The estimated and projected impact of HIV/AIDS on
life expectancy of selected countries……………………… 51
Table 4.1
Summary of the demographic indicators in Lesotho
(1976, 1986, 1996 and 2006)……………………………… 73
Table 4.2
Estimated number of HIV positive births in Lesotho
(2002-2010)…………………………………………………74
Table 4.3
Estimated cumulative AIDS deaths in Lesotho
(2002-2010)………………………………………………...74
Table 4.4
The number of deaths due to HIV/AIDS in Lesotho
in 2008…….......................................................................... 75
Table 4.5
The demographics of the respondents………………………80
Table 4.6
The most affected gender by AIDS in Lesotho…………… 83
Table 4.7
AIDS mortality by age in Lesotho
from the empirical study…………………………………… 84
Table 4.8
General views of the respondents on the impact of
HIV/AIDS in Lesotho……………………………………… 88
XIV
LIST OF ACRONYMS
ABC
Abstain, Be faithful and/or use Condoms
AIDS
Acquired Immune Deficiency Syndrome
ARV
Anti Retrovirus
BOS
Bureau of Statistics
CEO
Chief Executive Officer
CHAL
Christian Health Association of Lesotho
DMA
Disaster Management Authority
DRR
Disaster Risk Reduction
DTM
Demographic Transition Model
GOL
Government of Lesotho
HIV
Human Immunodeficiency Virus
IAVI
International AIDS Vaccine Initiative
IFRC
International Federation of the Red Cross and Red Crescent
ILO
International Labour Oganisation
LVAC
Lesotho Vulnerability Assessment Committee
MOHSW
Ministry of Health and Social Welfare
NAC
National AIDS Commission
OVC
Orphans and Vulnerable Children
PAR
Pressure and Release
PLWHA
People Living With HIV and AIDS
PMTCT
Prevention of Mother to Child Transmission
PRB
Population Reference Bureau
UNAIDS
Joint United Nations Programme on HIV/AIDS.
UNECA
United Nations Economic Commission for Africa
UNDP
United Nations Development Programme
UNISDR
United Nations International Strategy for Disaster Reduction
UNOCHA
United Nations Office for the Coordination of Humanitarian Affairs
USAID
United State Agency for International Development
USDOL
United States Department of labour
WHO
World Health Organisation
XV
CHAPTER ONE
METHODOLOGICAL ORIENTATION
1.1 INTRODUCTION
The research is carried out within the context of disaster management which is an interdisciplinary and multi-sectoral field of scientific enquiry (Kesten, 2008). The study investigates
the impact of HIV/AIDS (as a disaster) on the population structure of Lesotho. The Kingdom of
Lesotho, henceforth Lesotho, is the study area for this research. Lesotho, is a small, independent
and poor country in southern Africa, with a total surface area of 30355km2 and an estimated
population of 1,880 661 people (BOS, 2007:2). About 59% of the total population of Lesotho
lives below the poverty line and some 40% fall in the ultra-poor category (FAO, 2007:1). The
country has been ranked 149 out of 174 in the human development index (GOL, 2006:4; UNDP,
2006). The country is divided into ten administrative districts and is completely surrounded by
the Republic of South Africa (Figure 1.1)
Figure 1.1: Administrative districts of Lesotho
Source: Mapsofworld.com
1
The progression of vulnerability which is illustrated in the Pressure and Release (PAR) Model
(Wisner, Blaikie, Cannon & David, 2004:51) is used as the main theoretical framework for this
study. The rest of this chapter is built with this framework in mind. The next section outlines the
reasons and the worth of this research.
1.2 RATIONALE FOR THE CHOICE OF THE TOPIC
Rationale explains why the research is worth doing and is often supported by the literature
review (Hofstee, 206:89). The research is about a topical issue that still poses serious challenges
to academics and researchers from all walks of life.
HIV/AIDS is a disease which affects almost all countries in the world, killing millions of people,
especially in Africa, the poorest continent which has already been devastated by civil wars and
now is the seat of HIV/AIDS (Jackson, 2002:32-33). In 2006, there were close to 40 million
people in the world living with HIV and over 20 million had died of AIDS (Whiteside, 2008:4).
Sub Sahara Africa represents only about 11% of the world‟s 6.7 billion people (PRB, 2008:3) but
accounts for about 67% of all those living with HIV/AIDS (UNAIDS/WHO, 2008:5). About
25.3 million Africans have died of AIDS including 2.3 million in 2004 alone while 55 million
Africans are estimated to die of AIDS by 2020 (UNAIDS/WHO, 2004).
Lesotho is the third highest HIV infected country in the world, with an adult prevalence rate of
23.2%. The first country is Swaziland with 33.4% followed by Botswana with 24.1% (UNAIDS,
2007:11). HIV/AIDS was declared a national disaster in Lesotho in 2000 by His Majesty King
Letsie III (GOL, 2006:2). Despite this, it seems HIV/AIDS is not managed like other natural and
human-induced disasters in Lesotho. A comprehensive and coherent demographic impact of the
epidemic is not well documented and there is still information gap in the country (Moeti, 2007:1
and 23). HIV/AIDS is a topical issue in the world today with research from various scientific
fields, including the human sciences. However, despite more than three decades of research on
HIV/AIDS, the population pyramids of even the highly infected countries like Lesotho are still
the same in many publications.
2
The decision to undertake this research is motivated by the researcher‟s personal experience
with the HIV/AIDS situation in Lesotho, a burning desire to make an academic contribution to
this topical issue of HIV/AIDS and to investigate HIV/AIDS as a disaster that can be managed
from a disaster management perspective. The fact that no comprehensive and coherent studies
exist on the demographic impacts of HIV/AIDS in Lesotho from a disaster management
perspective, created an important research niche for the researcher.
However the researcher cannot address all the impacts of HIV/AIDS and their various
implications in relation to disaster risk reduction at an exhaustive scale but suggests that the
findings from this research will be a good starting point on which to build more blocks,
especially given the strategic choice of the location of the research. Besides the findings from the
research could easily be extrapolated to other highly HIV/AIDS infected countries in Southern
Africa such as Swaziland, Botswana, South Africa, Zimbabwe and Zambia.
The time frame from 1976 to 2006 (and even beyond) is used; giving three decades of
observation period and this period is enough to show significant changes in the demographic
processes in Lesotho that could be attributed to HIV/AIDS. The progression of vulnerability is
examined using the Pressure and Release (PAR) Model to explain the weaknesses in the country
that were exploited by HIV/AIDS to create these impacts. From the research, demographers and
cartographers should be better placed to see if there is need to redraw the Population Pyramids of
countries heavily infected with HIV/AIDS such as Lesotho. Policy makers in Lesotho should
also see the need to realign resources and strategies to combat HIV/AIDS and its effects in the
country. The research could also provide a useful reference tool for scholars and other
researchers interested in the study of HIV/AIDS as a disaster in Africa, especially in southern
Africa. The next section examines why the research is worth doing.
1.3 SIGIFICANCE OF THE RESEARCH
No research will be valuable if it does not contribute to the scientific knowledge in the domain in
which the research was conducted, help to solve a pertinent problem or build on the existing
3
knowledge of the research field (De Vos, Strydom, Fouche & Deport, 2005:112 and 116).
Consequently, this research could:
 Contribute in the understanding of the management of HIV/AIDS epidemic in the
context of disaster risk reduction.
 Assist policy makers in Lesotho to realign their HIV/AIDS policies and strategies
in up scaling the epidemic.
 Likely to be used to redraw the population pyramids of Lesotho and other
HIV/AIDS highly infected countries especially in southern Africa.
 Advance the knowledge and practice of the disaster risk management profession
in Lesotho.
1.4 RESEARCH STATEMENT, PROBLEM AND HYPOTHESIS
The research statement, the research problem and some hypotheses are stated below
1.4.1 Research statement
The research is guided by the point of departure that HIV/AIDS is a disaster in Lesotho and like
any other disaster, it can be approached in the context of disaster management involving multidisciplinary and multi-sectoral approach (South Africa Disaster Management Act number 57 of
2002:6). From a disaster management perspective, the new paradigm focuses on disaster
preparedness, prevention and mitigation but not neglecting emergency response, recovery and
rehabilitation of the disaster management continuum (UNISDR, 2002:18). Disaster is a function
of risk (UNISDR, 2002:25) and risk has three main components as seen in the risk equation
below (Wisner et al. 2004:49):
Risk (R) = Hazard (H) x Vulnerability (V) or R = H x V
Capacity (C)
C
4
(UNISDR, 2002:41)
This research uses the PAR model to examine the vulnerability side of the equation to explain
the demographic impacts of HIV/AIDS on the population structure of Lesotho.
There has been no coherent and systematic study of the impact of HIV/AIDS on the population
structure of Lesotho ever since the first HIV/AIDS case was reported in 1986 (UNDP, 2007:45).
More than two decades is a good time frame to start realising considerable impacts of such a
disease at such a scale with such intensity, given that the average lifespan of an HIV infected
person is taken to be ten years (UNAIDS/WHO, 2004). HIV/AIDS was declared a national
disaster in Lesotho in 2000 (GOL, 2005) and disasters normally have serious human impacts that
need to be mitigated after careful investigation. Such an investigation is the essence of this
research.
1.4.2 The research problem
Research problems could also be stated in the form of research questions in order to focus the
research (Mouton, 2001:53). In other words, research questions are used to name as precisely as
possible what the study will attempt to find out (Hofstee, 2006:85).
The research problem in this research is presented in the form of research question and is stated
as follow:
“What are the demographic impacts of HIV/AIDS in Lesotho and how have these impacts
changed the population structure of Lesotho?”
1.4.3 Research questions
The research questions that direct this research are:
Which demographic processes have been affected by HIV/AIDS in Lesotho?
How can the impacts of HIV/AIDS be linked to the progression of vulnerability in Lesotho?
Which population groups are more vulnerable to the impact of HIV/AIDS?
What are the impacts of HIV/AIDS on children as a vulnerable group?
5
How has HIV/AIDS affected the resilience of the society?
How is HIV/AIDS managed in Lesotho, compared to other disasters?
1.4.4 Hypotheses
Given the HIV/AIDS situation in Lesotho (like in many other countries in southern Africa), the
following might be expected:
Most of the demographic processes in Lesotho should have been affected and their
impacts should reflect on the current and future population structure
HIV/AIDS impacts should have exploited the progression of vulnerability in Lesotho
to become a disaster
HIV/AIDS has negatively affected all components of the population structure of
Lesotho
Although HIV/AIDS was declared a disaster, it may not be managed like other
disasters in Lesotho
Lastly, the number of HIV/AIDS orphans should be expected to rise even further in
Lesotho
All these hypotheses would probably have considerable socio-economic effects on the economy
and resilience of Lesotho.
1.5 THE AIM, GOAL AND OBJECTIVES OF THE RESEARCH
The aim and objectives of this research are stated below as follow:
6
1.5.1 Aim
The aim of this research is to engage in an exploratory and descriptive investigation of the
demographic changes in Lesotho and how these changes could be linked to the impacts of
HIV/AIDS. The research will draw the attention of policy makers in Lesotho to the fact that
HIV/AIDS could be managed as a disaster using certain disaster management principles,
practices and models. The research should also be able to establish the need to redraw the
population pyramid of countries highly affected by HIV/AIDS like Lesotho. Lastly, the research
should be able to advance the disaster management profession.
1.5.2 Goals
To achieve the aims mentioned above, the research goals are divided into the main goal and five
secondary goals. However, both the main and the secondary goals are interlinked and
complimentary.
Main Goal:
 To determine and describe the impacts of HIV/AIDS on the demographic processes
of Lesotho since the first case of HIV/AIDS was diagnosed in 1986 and to explore
measures that could prevent and or mitigate such impacts.
 Highlight these demographic impacts and redraw the population pyramid for Lesotho
that accommodates the impacts of HIV/AIDS.
It will be a historical-descriptive study (Mouton, 2001:170) of the demographic processes as well
as some quantitative overview of the changes in the demographic trends in Lesotho that could be
attributed to the effects of HIV/AIDS.
Secondary Goals:
 To examine the changes in the main demographic parameters in Lesotho with more
attention from 1976 to 2006 and link these changes to the impact of HIV/AIDS.
7
 To use the progression of vulnerability concept to establish the impacts of HIV/AIDS
in Lesotho and thus advance the knowledge and practice of the disaster risk reduction
paradigm.
 To establish the need to manage HIV/AIDS as a disaster in Lesotho and advance the
disaster management profession.
 To avail the results as well as some guidelines that may emanate from the research to
the stakeholders who are involved in the formulation and implementation of policies
and strategies to upscale HIV/AIDS in Lesotho.
 To determine how the conclusions and recommendations from this research could be
useful to other HIV/AIDS heavily infected countries in southern Africa.
1.5.3 The research objectives
The research objectives are distinguished for the literature and empirical investigation and they
are outlined as follows:
Objectives for the literature study
 To understand the meaning and historical background of HIV/AIDS
 To understand the global, regional and national demographic impacts of HIV/AIDS
 To formulate a useful link of the concepts in demography and those in disaster risk
management
 To establish a theoretical base for the study of HIV/AIDS as a disaster
Objectives for the empirical study
The objective of the empirical study is to compliment the secondary data that will be used
and to act as a form of triangulation. The empirical study will involve the following:
8
 Drawing up a questionnaire on the basis of the literature study and administering the
questionnaire to nurses, medical doctors and medical laboratory technicians who are
frontline people dealing with HIV/AIDS in Lesotho
 Engaging in a pilot study with five respondents to test the content of the questionnaire
and accordingly adjust the questionnaire on the basis of the pilot study
 Administer the adjusted questionnaire to randomly selected sample of the population
 Compare and interpret the collected data (both primary and secondary data) in terms
of simple descriptive statistics and then write the final research report
1.6 THE RESEARCH DESIGN
The research design is the plan or the blueprint of how the researcher intends to conduct his or
her research (Mouton, 2001:55). This is an empirical research issue (Mouton, 2001:144) and the
researcher intends to use a hybrid of both quantitative and qualitative methods but more of
quantitative approach to address the research theme. Quantitatively, the researcher intends to
follow the positivist approach (Kitchin and Tate, 2000:7-9; De Vos et al. 2005:5-7; Babbie,
Mouton, Vorster & Prozesky, 2008:12 and 22) and will use a lot of Secondary Data analysis
(Mouton, 2001:164-165).
However the researcher also intends to use questionnaires and an interview to generate primary
data that will be used to complement the secondary data mentioned above. The questions in the
questionnaire will be closed-ended questions (Kitchin and Tate, 2000:49-53) because closedended questions are suitable for this type of research, are easy to pre-code, input and analyse
using computer programmes such as the statistical packages for social sciences (SPSS) and the
spreadsheet. This mixed approach will serve as a form of triangulation (Rakotsoane and
Rakotsoane, 2006:12).
9
1.7 RESEARCH METHODOLOGY
A literature study, supplemented by an empirical investigation is used as the research method.
1.7.1 Literature study
The multi-discipline nature of disaster risk management guides the literature study and both
national and international sources are used. The literature flows from the general (global
situation) to the specific situation (the situation in Lesotho). The meaning and historical
background of HIV/AIDS is explored, followed by an overview of the global, regional and then
the national demographic impacts of HIV/AIDS.
The concept of demographic transition is explored to explain the changes in the trajectory of the
population of Lesotho as a result of HIV/AIDS while the Malthusian theory on population is
used as an awakening call. Initially, the progression of vulnerability is explored and the Pressure
and Release (PAR) Model is presented as a conceptual framework for the investigation in order
to explain the pathways that HIV/AIDS exploited to become a disaster in Lesotho.
1.7.2 Empirical investigation
The empirical investigation is based on the findings in the literature study. For the purposes of
empirical studies, both primary data (using questionnaires) and secondary data are generated to
explore and describe the impacts of HIV/AIDS on the population structure of Lesotho
To study the population structure of a country like Lesotho requires comprehensive data that can
be collected conveniently during a population census or a Demographic and Health Survey.
Unfortunately, both are in practice beyond the scope and limit of a single researcher. Besides, the
research touches on a very sensitive issue, which many people are not willing to freely talk about
due to the stigma attached to HIV/AIDS. Also various legislation in place and professional ethics
regarding the disclosure of AIDS related deaths make primary sourcing very difficult. It should
be acknowledged that this researcher is a full time teacher and the research is not sponsored by
anybody or organisation as mentioned elsewhere in the research. For all these reasons and given
10
the limited means and time at the researcher‟s disposal, the researcher will rely much on
secondary data sources.
Sampling strategy:
Though the researcher intends to use a lot of secondary data analysis especially population
censuses which have national coverage, the researcher also intends to send out questionnaires
with closed-ended questions to randomly selected medical officers and nurses, using a simple
random sampling. A demographer and a statistician from the Lesotho Bureau of Statistics (BOS)
will also be consulted.
Data collection:
The researcher intends to obtain the existing data from four national population censuses (1976,
1986, 1996 and 2006). These data will be cross-analysed with those collected during the
Demographic and Health Surveys (DHS) by the Lesotho Ministry of Health and Social Welfare
(MOHSW) in 2004. The DHS is conducted every five years and has a national representative
sample of people between the ages of 15-49 years (MOHSW, 2008). Data from the Antenatal
Clinic (ANC) HIV and Syphilis Surveillance for 2003, 2005 and 2007 as well as the Annual
Joint Review Report for 2008/2009 of the MOHSW will also be used. Any other data on
HIV/AIDS from the Lesotho National AIDS Commission (NAC), those published by the
UNAIDS and other HIV/AIDS monitoring institutions in Lesotho and southern Africa will also
be used. Besides, the researcher also intends to use questionnaires and an interview to generate
primary data to complement the secondary data available from the above-mentioned official
sources.
Data analysis:
The majority of the data analysis will be presented using simple descriptive statistical techniques
and facts and figures will be presented in the form of tables, graphs and diagrams. A combination
of univariate and bivariate analysis (Babbie et al. 2008:422 and 431) will be used. The service of
a senior statistician from the Lesotho Bureau of Statistics will be solicited. The facts and figures,
tables and diagrams will then be used to clearly support the logical conclusions and
recommendations that will be made by the researcher.
11
Pilot study:
The researcher intends to carry out a pilot study in Maputsoe in the Leribe district (see figure 1)
close to where the researcher resides. The pilot study will comprise of a medical doctor and four
nurses. This pilot study will help the researcher determine if the questions in the questionnaire
are well framed and understood.
Ethical considerations
There are important ethical issues that need to be taken into consideration when conducting
research (De Vos et al. 2005:57-58) and some of these issues are explained in this paragraph.
The researcher is aware of the sensitive nature of the research problem and will therefore act
responsibly to those who will participate in the research, respect the ethics of research and
respect the code of conduct of the disaster management profession. There will be no plagiarism
throughout the research and all sources of data and information will be acknowledged. The right
procedure will be followed to obtain data and information. No respondent will be deceived or
coerced to complete the questionnaire and any possibility of emotional harm to the respondents
will be avoided. Confidentiality and anonymity of the respondents will be adhered to. The
researcher will be objective and will avoid value judgment throughout the research process.
1.8 DEMARCATION OF THE INVESTIGATION
Both local and international sources are used for the literature study and the literature study
covers subjects like demography, population geography, disaster risk management, and studies
related to HIV/AIDS.
Although the research is restricted geographically to Lesotho, regional and even global
information is also provided to give the study a strong theoretical foundation. The time frame
between 1976 and 2006 guides the research but recent data and information will also be
included. The flow in the investigation is in the form of an overturned triangle, that is, from the
global, to the regional and down to the national situation.
12
Coming from a disaster management background, a multi disciplinary framework is used,
involving two models. The pressure and release model is used to explain the progression of
vulnerability to the impacts of HIV/AIDS and the demographic transition model is used to show
the effects of HIV/AIDS on the overall evolution of the population of Lesotho.
1.9 DEFINITION OF CONCEPTS
The following concepts are explained as they are consistently used in the research. A statement is
also made as to why they are used and how they relate to the research problem. Other technical
words are explained in the body of the research.
1.9.1 Birth rate or fertility rate.
For simplicity sake, the crude birth rate (CBR) will be used in this research and it is defined as
the number of live births (b) in a year, divided by the total midyear population (p) of the country.
The result is multiplied by 1000 to reduce the number of decimals (Weeks, 2005:209)
Thus CBR=b/px1000.
Like the rest of Africa, the countries in southern Africa experience high birth rates. For example,
in 2003, the Republic of South Africa (RSA) had a CBR of 20.5 per 1000, Zimbabwe 23.3 per
1000, Lesotho 24.8 per 1000, and Botswana 33.6 per 1000 (US Census Bureau reproduced in
Weeks, 2005:594-598). Given the fact that HIV/AIDS infection reduces fertility and knowledge
of HIV influences fertility choices (BOS, 2005) one should expect changes in fertility rates in the
highly infected countries, such as Lesotho.
1.9.2 Death rate or mortality rate.
Again and for the same reasons mentioned in 1.9.1 above, the crude death rate (CDR) will be
used. It is the number of deaths (d) in a year, divided by the total mid year population (p) of a
country and multiplied by 1000 (Weeks, 2005:172).
CDR=d/px1000
13
CDRs in southern Africa were still high but falling before the advent of HIV/AIDS. However,
the whole gains from imported medical facilities and better hygiene are now being directly
affected by the impact of HIV/AIDS. The immediate and direct impact of HIV/AIDS on the
population is that it causes the death rate to increase abnormally (PRB, 2008). Those affected
most are usually in the active age group and as a result, the dependency ratio (the number of
people who an adult in the active age group takes care of) is affected. The dependency ratio
could be very high in countries with high HIV/AIDS infection rate like Lesotho.
1.9.3 Disaster
A disaster is a serious disruption of the functioning of a community or society causing wide
spread human, material, economic and environmental losses which exceed the ability of the
affected community or society to cope using its own resources (UNISDR, 2002:24 and 25). A
disaster is a function of the risk process. It results from a combination of hazards, conditions of
vulnerability and lack of capacity/resilience to reduce the negative consequences of a risk
(UNISDR, 2002:25).
HIV/AIDS is a biological disaster (Wisner, 2004:188) and according to Whiteside (2008: i),
HIV/AIDS is primarily a disease of the poor, be they poor nations or poor people living in rich
nations. Though there might be some link between HIV/AIDS and poverty through the interface
of vulnerability, it may not be taken as a causal relationship. HIV/AIDS was declared a disaster
in Lesotho in 2000 (GOL, 2006:2) but it is left to be proven if HIV/AIDS is managed as a
disaster in Lesotho.
1.9.4 Disaster management
Disaster management is a continuous and integrated multi-sectoral, multi-disciplinary process of
planning and implementing measures which aims at:
Preventing or reducing the risk of disaster;
Mitigating the severity or consequences of disaster;
Emergency preparedness;
Rapid and effective response to disasters; and
Post disaster recovery and rehabilitation (South Africa Disaster Management Act 57 of 2002:6).
14
The definition above is quite comprehensive because it covers all the elements of the disaster
management continuum and it is the definition adopted in this research. The disaster
management continuum shows the various phases of a disaster and the type of intervention that
is necessary at each phase (see figure 1.2).
Figure 1.2: The disaster management continuum
Source: Van der Linde and Jordaan, 2009:20
Without neglecting the disaster and post disaster interventions, the new paradigm in disaster
management (the Disaster Risk Reduction) is more proactive and places emphasis on pre-disaster
and non-disaster interventions. The disaster risk reduction (DRR) paradigm is explored in detail
later in the research.
15
1.9.5 HIV/AIDS
HIV/AIDS are two interrelated terms, which are often used together in the study of the AIDS
epidemic. HIV/AIDS are also used together in this research. AIDS is an acronym which stands
for Acquired Immune Deficiency Syndrome and it is caused by HIV (Jackson, 2002:3). HIV is
also an acronym for Human Immunodeficiency Virus, which belongs to the group of
Retroviruses, and the later belong to the Lentivirus (Jackson, 2002:3). HIV is related to Simian
(Monkey) Immunodeficiency Virus (SIV) but despite extensive research, the origin of HIV itself
and exactly how, when and where SIV crossed over to human beings are still unclear. This
uncertainty must have provoked the “dissidents” view of prominent people like former President
Thabo Mbeki of South Africa who in 1999/2000 argued that HIV does not cause AIDS but that
poverty does (Jackson, 2002:6). A person with the HIV is said to be “HIV Positive” and if not
well fed and treated will rapidly progress to an AIDS patient, which is a medical condition
during which the white blood cells are destroyed by the HIV to a level that they cannot fight
infections. At this stage, the CD4 cells count is so low that the body is exposed to opportunistic
infections that eventually lead to the death of the AIDS patient. AIDS has no known cure and it
has a 100% mortality rate (Jackson, 2002:1)
1.9.6 Lesotho
Lesotho is a small, independent and poor country in southern Africa, with a total surface area of
30355km2 and an estimated population of 1,880 661 people (BOS, 2007:2). About 58% of the
total population of Lesotho lives below the poverty line and the country has been ranked 149 out
of 174 in the human development index (UNDP, 2006; GOL, 2006:4). The country is divided
into ten administrative districts and is completely surrounded by the Republic of South Africa
(see figure 1.1). Lesotho is heavily affected by HIV/AIDS.
1.9.7 Migration
Defined as the movement of people from place to place both within (internal migration) and
between countries (international migration). Internal migration is mostly from the rural areas
where HIV/AIDS infection rates are lower to urban areas where the rates are higher in Lesotho
(BOS, 2005). International migration, especially in the case of Lesotho with many mine workers
16
has some correlation with HIV/AIDS infection rates which increase with increased duration and
frequency of the mine-migrants returning to Lesotho.
The case of trans-frontier truck drivers is also documented as a good vector for the transmission
and spread of HIV/AIDS (BOS, 2005). Also border towns are identified as HIV/AIDS hot spots
(Whiteside, 2008:13).
1.9.8 Population pyramid
Sometimes called the age pyramid, the population pyramid is a graphical representation of the
sex and age distribution of the population of a country (Weeks, 2005:329).
The shape of the population pyramid is determined by demographic factors such as fertility,
mortality and migration (Nicolau, 2003:50). These factors have been explained above. Sub
Saharan Africa is considered to have a youthful age structure which carries in them the potential
substantial momentum of population growth but which is being held back only by the HIV/AIDS
pandemic (Weeks, 2005:354-355). In 2007, 39% of the1.8 million people in Lesotho were below
15 years while only 5% were more than 65 years (PRB, 2008:8). This shows that Lesotho still
has a youthful age structure and this research will examine to what extent HIV/AIDS has
affected or will affect the quantity and quality of this youthfulness of the population as well as to
examine how HIV/AIDS has impacted on the ratios among the main population groups.
1.9.9 Population structure
The population structure of each country shows the number of men and women (sex ratio) for
each determined age group (age structure) and is usually depicted in the form of a diagram
commonly referred to as the Population or Age pyramid (Weeks, 2005:329). The population
structure is influenced by three processes, which are the birth rate, the death rate, and migration
(Nicolau, 2003:50). Since HIV/AIDS has a serious impact on these three processes, especially
the birth rate and the death rate, one should expect that this disease should have altered the
population structures and consequently the population pyramids of highly infected countries like
Lesotho.
17
1.9.10 Resilience
According to Smith and Petley (2008:15) resilience is a measure of the capacity to absorb and
recover from the impact of a hazardous event. One way to build community resilience is to
establish effective social networks (Jordaan, 2008). Unfortunately such social networks are
lacking in Lesotho; partly due to economic, social and cultural factors as explained later in this
research.
1.9.11 Vulnerability
Vulnerability can be seen as the degree to which an individual, a household, a community or an
area may be adversely affected by a disaster (South Africa Disaster Management Act 57 of
2002). Individuals, households or communities could face physical, social, economic or even
political vulnerability in the face of a potential hazard (UNISDR, 2002:21). Vulnerability is an
important component of the disaster risk equation and disasters occur only when hazards such as
HIV/AIDS hit people or communities that are very vulnerable and which lack resilience
(Jordaan, 2008). The antithesis of vulnerability is resilience and both are determined by physical,
environmental, social, economic, political, cultural and institutional factors (Benson,Twigg &
Tiziana, 2007:15). It can be said that human and societal vulnerability is the underlying cause of
most disasters.
The concepts and models as they are applied in the research problem are fully examined in
chapter three.
1.10 COMPOSITION OF THE RESEARCH REPORT
Chapter one provides a general orientation for the methodology of the research where the
research problem, the rationale for the research, the research question, the aim, the objectives and
some hypothesis are outlined. The research design and methodology, the demarcation of the
research as well as some concepts that are consistently used in the study are equally outlined and
explained.
18
General concepts and theories and their application in relation to the impacts of HIV/AIDS on
the population structure of Lesotho are discussed in chapter two as a conceptual framework for
the study within the discipline of disaster risk management. The rest of the research report is
presented using the background of this conceptual framework. In chapter three, the demographic
impacts of HIV/AIDS is given a theoretical base through the application of the conceptual
frameworks mentioned in chapter two in a detail literature study.
The collection, processing, description, interpretation and presentation of empirical data on the
basis of secondary data analysis and the questionnaire for generating primary data are presented
in chapter four. The interpretation and presentation of the empirical data are guided by both the
conceptual framework of the study (Chapter two) and the scientific exploration of the research
theme (Chapter three)
In the last chapter (Chapter five), the conclusion and recommendations are outlined on the basis
of the literature study, secondary data analysis and the empirical investigation.
The entire research report therefore comprises of four main parts which include an orientation
(Chapter one), a literature review (Chapter two and three), SDA and an empirical investigation
(Chapter four) and a conclusion and recommendations (Chapter five).
1.11 SUMMARY
This chapter outlines the general orientation for the study of the phenomenon of HIV/AIDS on
the population structure of Lesotho. It begins by explaining the framework within which the
research is done, followed by the reasons guiding the choice of the topic. The chapter then
proceeds to outline the research statement as a point of departure of the research. The research
theme is then explored under the research questions and then some tentative untested statements
are postulated in a couple of hypothesis. This is directly followed by what the study aim to
achieve and then the approaches and procedures that is used to conduct the research under
research design and research methodology. The study is then demarcated and consistently used
terms are explained. Finally an outline of how the final research report looks like is presented.
19
CHAPTER TWO
AN INTEGRATED CONCEPTUAL FRAMEWORK FOR THE STUDY OF
THE IMPACT OF HIV/AIDS DISASTER ON THE POPULATION
STRUCTURE OF LESOTHO
2.1 INTRODUCTION
The demographics of Lesotho are being changed drastically by the prevalence of HIV/AIDS
which makes it necessary to put in place strategies and tactics to respond to the epidemic from a
disaster risk reduction perspective. This study is contextualised within the disaster risk
management discipline using the pressure and release (PAR) model as the main theoretical
framework for the research (Blaike, 1994). The PAR model demonstrates how dynamic
pressures transform root causes to create unsafe conditions in a community (Wisner et al.
2004:51). The model explains how the progression of vulnerability in Lesotho, exposes the
community to the demographic impact of HIV/AIDS pandemic.
Other models exist in disaster management that could explore, describe and explain the
demographic impact of HIV/AIDS on individuals, families, groups and communities. For
example the Access Model (Blaikie, 1994) explains how lack of access to resources by certain
group of people in a society increases their vulnerability to hazards like HIV/AIDS. The
Capacity and Vulnerability Analysis (CVA) model uses a matrix to view people‟s vulnerabilities
and capacities in three broad interrelated areas ( physical/material, social/organisational,
motivational/attitudinal) and CVA is mostly used by Non Governmental Orgainisations (NGOs)
to evaluate projects (Twigg, 2001:2). The Sustainable Livelihoods (SL) approaches integrate
poverty reduction strategies, sustainable development and participation and empowerment
processes into a framework for policy analysis and programming (Twigg, 2001:8 and 9). The
DMI‟s Victim Security Matrix (VSM) and Tunner model are other models in vulnerability
analysis. The Progression of Safety model (Wisner et al. 2004:344), is another model in the field
of disaster risk reduction and is actually the anti-thesis of the PAR model. The focus of the
Progression of Safety Model is that by addressing the root causes and reducing dynamic
20
pressures, a society can achieve safe conditions that will reduce its vulnerability to hazards and
therefore reduce disaster risks (Wisner et al. 2004:344). The PAR model, the Access model and
the Progression of Safety model are complimentary models in disaster risk reduction studies
(Wisner et al. 2004:50).
Though the PAR Model is used in the research as the main theoretical framework, disaster risk
management is an inter-disciplinary and multi-sectoral discipline (Kesten, 2008) and therefore
the nature of the discipline as well as the nature of the research topic makes it difficult to use a
single theory or model to address the research problem and the research questions. Consequently,
the researcher also uses the demographic transition model (DTM) and alludes to the Malthusian
theory on population growth to highlight the impact of HIV/AIDS on the population of Lesotho.
The meaning, relevance and application of the DTM to the demographic impact of HIV/AIDS in
Lesotho are explained later in the chapter. A closer look at the PAR model and its relevance to
the research is explored in the next sub section.
2.2 THE PRESSURE AND RELEASE (PAR) MODEL AND ITS APPLICATION TO THE
IMPACTS OF HIV/AIDS IN LESOTHO
In the 1980s and 1990s, two important conceptual models were developed to give Disaster
Managers a framework for understanding vulnerability to disasters (Twigg, 2001:2).The models
include Capacity and Vulnerability Analysis (Aderson and Woodrow 1989/1998) and Pressure
and Release/Access models (Blaikie, 1994) in (Twigg, 2001:1). The PAR model is used in the
research and it is explained below:
The PAR model explains the progression of vulnerability in a society and shows that a disaster
only occurs when hazards like HIV/AIDS afflict vulnerable societies that also lack coping
capacities to such hazards (Wisner et al. 2004:50). The pressure in the PAR Model comes from
two opposing direction; the hazard direction and the vulnerability direction while the release is
how the impacts can be reduced by reducing vulnerability (Wisner et al. 2004:50). The
progression of vulnerability consists of three interrelated parts which shows how dynamic
pressures translate root causes into unsafe conditions (Wisner et al. 2004:50). See figure 2.1
21
Figure 2.1: The Pressure and Release (PAR) Model
Source: Wisner et al. 2004:51
In the following subsections, each component of the model is explained with relevance to the
demographic impact of HIV/AIDS in Lesotho.
2.2.1 Root or underlying causes
The root causes are the most remote influences of vulnerability, the most distanced both in space
and time, the most unnoticeable and often ignored but the most dangerous that slowly destroys
the resilience of the community or society. These root causes include:
Limited access to power, structures and resources, regressive ideologies, political system and
economic systems (UNISDR, 2002:73)
22
Viewed in another way, these root causes operate in the form of economic, demographic and
political processes which affect the allocation and distribution of resources among different
groups of people and are a function of economic, social, and political structures, legal
frameworks and the enforcement of human rights, gender relation and elements of ideological
order (Wisner et al. 2004:52). Root causes are also seen as the function or the dysfunction of the
state, nature of control by the police and military, good governance and the rule of law (Wisner
et al. 2004:53)
The root causes are treated in the research as those distant and sometimes neglected factors but
that are the building blocks of vulnerability to the impact of HIV/AIDS hazard in Lesotho. Only
the root causes which have relevance to the demographic impact of HIV/AIDS in Lesotho are
discussed. Prominent among them are economic factors such as the escalating level of poverty in
the country, limited natural resources, weak and undiversified economy. Other root causes
discussed include socio-cultural issues like traditional beliefs and ideologies while the political
factors that revolve around the issues of lack of access to power structure and instability in the
political system of the country are all highlighted below.
Economic factors
The high level of poverty remains the main cause of vulnerability of the Basotho to the impact of
HIV/AIDS. Of a total population of 2.3 million people in 2003, 948,310 were “Poor”, 621,610
“Middle” and a dismal 238,080 “Better Off”.(LVAC, 2004:4). Another source reports that 50%
of the Lesotho population live below the poverty level, 54% of rural households are poor while
29% are ultra poor (MOHSW, 2008:6). The poverty percentage of MOHSW are lower than those
of the Food and Agricultural Organisation (FAO) which states that 59% of the Basotho live
below the poverty line while 40% are ultra poor (FAO, 2007:1). Ranked 149 out of 177 in the
Human Development Index of the UNDP (UNDP, 2006), Lesotho is a Least-Developed country
with food deficiency and chronic malnutrition conditions and is therefore a classical example of
a poor country in the world. Lesotho is particularly vulnerable to the triple threats of food
insecurity, HIV/AIDS and weak capacity for governance and service provision (FAO, 2007:1).
These triple threats have exacerbated the demographic and other impacts of HIV/AIDS in
Lesotho because these triple threats are interlinked and they all reduce the resilience but increase
23
the vulnerability of the society to the impact of external shocks or hazards. Although hazards like
HIV/AIDS could induce crisis, the prevailing conditions in the society (in this research Lesotho)
with regards to the population‟s vulnerability or coping capacity determines the susceptibility or
resilience of the population to loss or damage (UNISDR, 2002:13; DFID, 2006:5). Poverty has a
great role in increasing vulnerability and weakening coping capacities in Lesotho and therefore
exposing many Basotho to the impact of HIV/AIDS.
Poverty has also forced many adults and energetic Basotho to migrate from the rural to urban
areas with the hope of getting a job and living a better life, or to migrate to the Republic of South
Africa (RSA) especially male adults to look for jobs in the mines. Both situations increase the
vulnerability of these displaced people to the impact of HIV/AIDS. In South Africa, HIV/AIDS
prevalence rates are higher among mine workers who are also good vectors for the spread of
AIDS to their spouses especially those mine workers from Lesotho and Mozambique
(Jackson,2002:30; GOL, 2006: x; Moeti,2007:24)
The process of rural-to-urban migration creates very vulnerable situation in that the aged,
women and children are left in the rural areas to cultivate and rear animals with a resultant low
output which creates conditions of food insecurity (LVAC, 2004). Besides, the young girls who
migrate to towns most often cannot find jobs in the few clothing factories. They are therefore
forced into prostitution, “Likoena” as they are popularly called with the result that these helpless
young girls are highly exposed to contract the ravaging HIV/AIDS (UNGASS, 2008:16).
Another economic factor that increases vulnerability and is relevant to HIV/AIDS in Lesotho is
the lack of availability of social networks that could mobilize support outside the household
(Smith and Petley, 2008:18). This lack of social networks affects the resilience of the society to
external shocks like HIV/AIDS. Although the lack of social networks could have a cultural
underpinning, economic factors also play a great role because “One cannot give what one does
not have.” How to build strong community resilience with good social networks could be
investigated in a further research.
24
Natural resources
Lesotho has few natural resources. Apart from water and a shallow diamond deposit at Letsie-La
Terre in Mohotlong district, the country generally lacks natural resources unlike her immediate
neighbour the RSA. About 75% of the total land surface is mountainous and is covered by hard
sedimentary rocks with only 10% of the land suitable for agriculture (World Bank, 2005:2).
Lesotho lost most of her arable lowland to the Free Staters, a sub group of the Trekkers in the
mid 19th century during the Basotho Wars. These wars were fought between King Moshoeshoe I
(the founder of the Basotho nation which is today called the Kingdom of Lesotho) and the
Trekkers (a group of Afrikaners who formed part of the Orange Free State province in southern
Africa) displaced from the Cape Colony by the British settlers (Tylden, 1950:13-18). Meanwhile
the piedmont area in Lesotho is seriously ravaged by erosion leading to a lot of wasteland in the
form of dongas. Looking at the extent and intensity of soil erosion in the country, the researcher
is of the opinion that soil erosion should be declared a national disaster in Lesotho. The
phenomenon of soil erosion and its impacts in Lesotho could be investigated in detail in another
research. Non-the-less, serious soil erosion creates the problem of lack of arable land for
production. The lack of arable land partly explains the problem of food insecurity in Lesotho and
when people are poorly fed or have no food to eat, their immune system is affected rendering
them vulnerable to HIV/AIDS. Besides, lack of arable land is documented as a push factor in the
rural-to-urban migration process with all its attendant risks including being vulnerable to
diseases like HIV/AIDS (Weeks, 2005:460-461). Migration as a phenomenon is discussed
further under dynamic pressures.
Socio-cultural root causes
Culture also has a role to play in the vulnerability of Basotho to HIV/AIDS. Gender inequality
and the attitude of men towards heterosexual relationship create vulnerable conditions to
HIV/AIDS (UNDP, 2006:47). Gender inequality, gender-based violence, low socio-economic
and legal position for women and lack of empowerment of women to make decisions, all of
which are common in Lesotho are all factors fueling the vulnerability of women to the impact of
HIV/AIDS (GOL, 2006:X; MGYSR, 2006:12).
Women still hold minority status, cannot negotiate safe sex and are often subjugated in
marriages with no legal independence (UNDP, 2006:47). Cultural perceptions of women‟s
sexual and reproductive obligations increase their vulnerability to HIV/AIDS. For example, the
25
payment of bride price gives men the impression that they own their wives and therefore that
their wives cannot negotiate when and how to have sex thus increasing women‟s vulnerability to
HIV/AIDS (UNDP, 2006:47). The culture of silence which could partly be attributed to fear and
intimidation as observed by the researcher among female students not only increases their
vulnerability to HIV/AIDS and other STIs but also contributes to increase teenage pregnancies
and dropouts from schools in Lesotho.
The practice of widow inheritance where a woman is inherited by his deceased brother,
sometimes with the cause of the death not clear is a factor that leads to the spread of HIV/AIDS
(Whiteside, 2008:46). Besides the practice of “dry sex”, where herbs and other agents are used to
dry out the vagina with the believe that the practice increases men‟s pleasure during sex (Barnett
and Whiteside, 2006:46; Whiteside, 2008:46) not only increases the vulnerability of women to
HIV/AIDS infection but again testify the weak position of women when it comes to negotiating
sex with men.
The culture of denial is a big problem in Lesotho (Moeti, 2007:7). Some people feel HIV/AIDS
does not exist and even those tested positive refuse to admit their status. The culture of denial
helps to fuel the spread of HIV/AIDS in Lesotho. The researcher has observed that traditional
initiation schools are catalysts to many dropouts from formal education and have encouraged
child labour especially in herding cattle. These traditional initiates quickly adopt adult life styles
including early marriage and therefore early sex debut. Early sex debut is documented as a factor
that increases the chances of contracting HIV/AIDS (UNGASS, 2008:35 and 36).
Besides, the use of the same razor blade to circumcise many initiates has been documented as a
practice that promotes the spread of HIV/AIDS (UNGASS, 2008:30).
A contradictory situation has been observed in Lesotho in that HIV/AIDS is generally higher
among uncircumcised men than among the circumcised men (BOS, 2005:240). This
contradiction is probably because circumcision takes place late in Lesotho when the men have
already been infected with HIV/AIDS. According to SAfAIDS (SAfAIDS, 2008:1), male
circumcision could be an efficacious, long lasting and cost effective strategy for combating HIV
in high-prevalence countries such as Lesotho. Therefore the tricky observation between
26
circumcision and HIV/AIDS in Lesotho mentioned above could give a wrong signal and it is
advised that the situation be handled with care and precaution.
Some misconceptions about the causes of HIV/AIDS which could be associated to lack of
knowledge and education also increase vulnerability. Among these misconceptions are that
HIV/AIDS is caused by supernatural means, mosquitoes bites, sharing food and utensils with an
infected person, kissing an infected person, healthy looking people cannot be infected etcetera
(BOS, 2005:184). These erroneous beliefs could lead to stigmatization of people living with
HIV/AIDS (PLWHA) as well as break down in social networks in the society.
The historical demographic imbalance in the sex ratio in Lesotho with more female and less men
(BOS, 2007:6) plays a role in the vulnerability of Basotho to HIV/AIDS as it predisposes the
culturally minded few men to having multiple sex partners. Having multiple sex partners is an
important factor that fuels the spread of HIV/AIDS (GOL, 2006:8). Though Whiteside (2008:46)
is of the opinion that the number of sexual partners per se seems less important in the spread of
HIV/AIDS, this view is not shared by many others including this researcher. It will be difficult
for one man to socially and biologically satisfy the needs of his multiple sexual partners or one
woman to do same for her multiple male sexual partners. The situation promotes infidelity and
increases the chances of contracting HIV/AIDS.
The practice of intergeneration sex especially between older men and younger women, leads to
increase vulnerability especially among young women to HIV/AIDS (GOL, 2006:X; Whiteside,
2008:49; UNGASS, 2008:33). These older men are more predisposed to HIV/AIDS by virtue of
their age and given the fact that many of their female cohorts might have died of HIV/AIDS
since AIDS deaths show gender bias in disfavour of females (Whiteside, 2008:63). The
intergeneration sex practices are also encouraged by transactional sex whereby young women
indulge in sex with older men in order to acquire material things like expensive dresses, cell
phones and even cars.
Cultural factors have a big role to play in the vulnerability of the Basotho to the impact of
HIV/AIDS and since it takes a long time to change deeply rooted cultural norms and practices,
27
the researcher is of the opinion that the impact of HIV/AIDS may be felt longer than anticipated.
This opinion is supported by studies which observed that despite high level of awareness, there
has been little or no change in attitude towards HIV/AIDS in Lesotho (Moeti, 2007:14;
UNGASS, 2008:42). Besides socio-cultural factors, political factors also influence vulnerability
to the impact of HIV/AIDS in Lesotho.
Political factors
The socio-economic vulnerability of people in a country can be impacted upon positively or
negatively by the way the social and economic policies of the country are formulated with
regards to how the national resources are exploited, utilized and distributed which in turn is
influenced by the political system (Kimaryo, Opaku, Githaku-Shongwe & Feney 2004:55). Poor
governance influences the ability of a country to mitigate and manage disaster risk including
HIV/AIDS (DFID, 2006:7). Besides, the so called natural disasters are more political than
natural regardless of the hazard that triggered the disaster (UNISDR, 2002:8). Lesotho inherited
the capitalist economic system and with little alteration, the system is still in place. The national
wealth is concentrated within a small portion of the population while the majority live below the
poverty line (Phamotse, 2008:2; MOSH, 2008:5). The role of poverty with regards to the impact
of HIV/AIDS is encapsulated in the statement by Whiteside (2008: i) who is of the opinion that
HIV/AIDS is a disease for the poor, be it poor countries or poor people living in rich countries.
Apart from HIV/AIDS, most disasters affect poor countries and poor people the most (DFID,
2006:3).
Therefore, formulating and implementing effective poverty reduction policies and strategies in
Lesotho will help to reduce the impact of HIV/AIDS.
Though Nattrass (2006:11) is of the opinion that there is no clear evidence between AIDS and
political stability, there is evidence that support the fact that democracy fosters development
while the fragile democracies in southern Africa and the heavy AIDS burden could lead to
dictatorship and dictatorship is counter development. Besides lack of effective central
government, incompetence and corruption creates weak organisational structures and deficient
welfare programmes which all increases vulnerability of the society to external shocks such as
HIV/AIDS (Smith and Petley, 2008:19). Therefore directly or indirectly, political factors are
28
linked to HIV/AIDS. Some politicians are even skeptical on the need for HIV/AIDS mitigation
on the ground that there is lack of data on the impact of AIDS on the economy (ECA-SA,
2006:37). This type of view might have caused the late response to HIV/AIDS by the
government of Lesotho (Moeti, 2007:24). Even when the response did come, policy makers in
Lesotho like the case in many other countries look at HIV/AIDS as clinical-medical problem and
only realized later that HIV/AIDS required a much broader perspective and that it even had to do
with human rights (Barnett and Whiteside, 2006:76-78). Political views on HIV/AIDS from
prominent politicians like former president Thabo Mbeki of South Africa who in 1999/2000
argued that HIV does not cause AIDS but poverty does, can only increase the vulnerability of
people to the pandemic (Jackson, 2002:6). The researcher is of the opinion that though poverty
increases people‟s vulnerability to HIV/AIDS, poverty cannot be a causal factor and therefore
the statement by former president Mbeki can only be valid if poverty is seen as one of the factors
that increases vulnerability of the society to the impact of HIV/AIDS.
The legal system in Lesotho put married women as legal minors and this constrain them to
negotiate contracts, own land and inherit immovable property (MGYSR, 2006:12). This practice,
though changing, was not empowering the Basotho woman. It rather compromised her socioeconomic status and made her more vulnerable to HIV/AIDS.
2.2.2 Dynamic pressures
Dynamic Pressures are factors that channel root causes into particular forms of insecurity that
have to be considered in relation to the type of hazards facing vulnerable people in the society
(Twiggs, 2001:4 and 5). Such dynamic factors include:

Lack of local institutions

Lack of training and appropriate skills

Lack of local investment and lack of local market

Lack of press freedom and poor ethical standards in public life.
Dynamic pressures also involve macro forces such as:

Rapid population growth and changes

Rapid urbanization

National debt repayment schedules
29

Deforestation

Decline in soil productivity and

Arm conflicts and expenditure (Wisner et al. 2004: 51-55)
Disaster impacts are exacerbated by dynamic pressures (DFID, 2006:6).Though there are
different dynamic pressures in the model, for the purposes of this study, only the lack of local
institutions and appropriate skills to handle HIV/AIDS, lack of local investment and weak local
market, rapid population change, rapid urbanization, wars and decline in soil productivity are
discussed under this sub section with reference to the demographic impact of HIV/AIDS in
Lesotho.
Lack of local institutions and appropriate skills
To reduce vulnerability to risk such as HIV/AIDS involves serious institutional implications; for
example the creation of disaster risk reduction department in all government institutions and a
central coordination body such as the disaster management centre. It requires the integration of
disaster preparedness and mitigation measures into long term development processes as well as
to put in place the right institutions for capacity building (DFID, 2006:14).
The fact that no such preparedness and mitigation measures or institutions were in place in
Lesotho till 2000 increased the vulnerability of the population to the impact of HIV/AIDS. The
Lesotho AIDS Programme Coordination Authority (LAPCA) was only established in 2000 to
help formulate the first policy framework on HIV/AIDS (GOL, 2006: xiii). This confirms
Lesotho‟s late response to HIV/AIDS because the first HIV case was reported in 1986
(MOHSW, 2008:2).
The Lesotho National Disaster Management Authority is a recent creation (National Disaster
Management Act No.26 of 1997) and the Authority lacks both human and financial resources for
its operations. The health system in Lesotho has been in shambles for years and this has forced
many nurses and doctors to either leave the public service or migrate to other countries
especially to the United Kingdom (Moeti, 2007:23). The departure of many nurses and doctors
also created a very high ratio of patients per doctor (MOHSW, 2008:6). Poor access to health
services increases the vulnerability of the Basotho to the impact of HIV/AIDS.
30
Lack of local investment and a weak local market
There is a general lack of local investment in Lesotho. This is partly caused by lack of access to
micro finances and loans, lack of entrepreneurial skills in Lesotho or due to poor work ethics and
fear of risks involved in business. Lesotho is basically a consumption economy of imported
goods with even the most basic goods and services imported from RSA. This leads to perpetual
deficits in her balance of payment. Such deficits are only corrected by either borrowing or from
foreign aid. The later has created dependency problem in Lesotho for even basic needs like food
supply. Over reliance on relief supply even in normal situations results in the perpetuation of
existing risks and creates a cycle of recurrent disaster (DFID, 2006:9). Such over reliance on
foreign aid does not build societal resilience and therefore increases the impact of hazards such
as HIV/AIDS. The researcher has observed that the few industries that exist in Lesotho and most
shops especially supermarkets are owned by foreigners mainly Chinese and Indians. Foreign
dominated investment does not empower a nation to become resilient to external shocks like
HIV/AIDS as most of the profit is repatriated rather reinvested in the country.
Spreading business risks through insurance is also a problem in Lesotho where only two main
insurance companies operate, the Metropolitan Insurance Company and the Lesotho Insurance
Company. The ethical standards of these companies in relation to meeting claims leaves much to
be desired and frustrates many people who would have liked to insure against disaster risks in
Lesotho including life assurance against the risk of HIV/AIDS. A very popular local insurance
company called MKM Lion Insurance Company which operated both funeral and investment
policies was declared insolvent since 2007 and is now facing liquidation with millions of
people‟s money trapped in the protracted dispute between the government of Lesotho and MKM
Lion Insurance Company. The researcher is one of the investors unable to get back even the
basic invested money in the company. Practices like the one just mentioned discourage local
investment and do not build societal resilience to cope with the impacts of hazards like
HIV/AIDS.
Rapid population increase
The population of Lesotho, like in many other developing countries was increasing rapidly
before the advent of HIV/AIDS. The rapid population increase was mainly due to high birth rates
31
which were close to 30 per thousand (PRB, 2008:8). The total population of Lesotho increased
from 1.8 million people in 1976 to 2.3 million in 2003, before dropping to about 1.9 million in
2006 (BOS, 2007:2). This drop in population is strongly linked to the effects of HIV/AIDS
(GOL, 2006: i). The rapid population increase before the advent of HIV/AIDS mounted
considerable pressure on environmental, economic and social infrastructure and resources with
negative consequences.
The rapid population growth, coupled with lack of environmental awareness produced serious
negative impact on the environment in Lesotho. Deforestation for fuel, both for heating during
the severe cold winter seasons and wood for cooking has robbed the steep slopes of vegetation
cover. Lack of vegetation cover exposes the land surface to various agents of erosion resulting to
dissected surfaces with deep V-shaped valleys and dongas.
The result of erosion is that there is fall in agricultural productivity and shortage of food supply
which is documented as one of the drivers of HIV/AIDS in Lesotho (GOL, 2006: x)
However, though the PAR model talks of rapid population change in terms of population
increase, the effects of HIV/AIDS has instead reduced the population of Lesotho. The situation
in Lesotho therefore raises the question as to whether the decrease in population due to
HIV/AIDS is part of the natural checks to population growth which Thomas Malthus talked
about as far back as 1798 (Weeks, 2005:77-80). Thomas Robert Malthus wrote about the causes
and consequences of rapid population growth. Malthus cautioned that if people do not apply
preventive measures to control birth rates, then natural checks such as famine, diseases, wars,
pestilence, cannibalism and others, would set in to check population growth. This school of
thought is popularly referred to in demography as the Malthusian perspective of population
growth (Weeks, 2005:77-87). Despite a lot of criticisms from the Marxist, neo classic and other
schools of thought, three centuries later with the advent of HIV/AIDS and other disasters, it
seems that Malthus‟s thinking and arguments still hold some relevance. The connection between
HIV/AIDS and the Malthusian theory on population growth needs to be investigated further.
Rapid urbanisation
Natural increase in cities and rural exodus (due to hardship I rural areas) has led to rapid
urbanization in Africa (Pelling and Wisner, 2009:39). Rapid urbanization is a major factor in the
32
growth of vulnerability especially for low income households who live in squatter settlements,
dangerous locations like hill slopes, flood plains and river valleys (UNISDR, 2002:70). Rapid
urbanization leads to pressure on the land as the new urban settlers meet already crowded cities
and are therefore forced to settle in unsafe land, encroach into the nearby forest and construct
unsafe habitats using the available building materials which are not resistant to hazards. These
slum-dwellers face greater risk to hazards like flood, strong winds, tornadoes, landslide and
mudflow (UNISDR, 2002:70).
Lesotho faces rapid urbanization with the main focus being the city of Maseru. Urban population
has increased from 10.5% in 1976 to 23.8% in 2006 (BOS, 2007:4).
The rapid urbanization has resulted in informal settlement around the periphery of the city of
Maseru with poorly constructed houses popularly called “Maliners”. These houses generally lack
basic facilities like toilets and bathrooms thus creating condition for outbreak of epidemics that
can weaken the immune system and increase the impact of HIV/AIDS.
One of the major causes of rapid urbanization is rural-to-urban migration, sometimes referred to
as rural exodus (Weeks, 2005:460). Rural-to-urban migration as well as out migration of the
Basotho especially as mine workers to South Africa are some of the dynamic pressures that
increase vulnerability to HIV/AIDS in Lesotho (Whiteside, 2008:50 and 51). Rural-to-urban
migration reduces food production in Lesotho because the labour supply in the agricultural sector
is reduced and this leads to food insecurity and malnutrition. Lack of food weakens the immune
system and creates opportunity for HIV/AIDS infection and subsequent death. Meanwhile,
migrant mine workers are reported to be good vectors for the spread of HIV/AIDS in Lesotho
(GOL, 2006: x; Whiteside, 2008:50 and 51). These mine workers live in single sex hostels and
are separated from their spouses. They are therefore exposed to same sex practices, or have
concurrent multiple sex partners while away from home which make them very vulnerable to the
impact of HIV/AIDS.
Global economic pressures
The fall in prices of agricultural and mineral products but with a corresponding increase in prices
of technical, manufactured and energy products in the1980s coincided with the period when the
33
first HIVAIDS cases were reported in sub Saharan Africa. The fall in prices of these primary
products resulted in serious indebtedness for the Less Developed Countries (LDCs) and the
servicing of these debts take up as much as 50% of their GDP (UNISDR, 2002:76). Attempts to
pay these debts have led to over exploitation of natural resources leading to environmental
degradation with corresponding health risks.
The Structural Adjustment Programmes (SAP) prescribed by the International Monetary Fund
(IMF) and the World Bank has led to cut back in social services including health services and the
privatization of state owned corporation, has produced market prices and has instead increased
the vulnerability of the very poor in the society (World Bank, 2005). Lesotho like many African
countries is implicated in global economic pressures.
For example the recent world crisis has led to reduction in funding for HIV/AIDS treatment in
developing countries especially in the eastern and southern African region (UNAIDS/World
Bank, 2009:1-3). Reduction in funding for the treatment of HIV/AIDS can exacerbate the impact
of HIV/AIDS in developing countries like Lesotho.
Wars
Wars in countries like Angola, Democratic Republic of the Congo, Mozambique, Eritrea etcetera
have devastating effects on people, their livelihood and their environment. Wars also produce
many refugees or Internally Displaced People (IDPs). This creates not only vulnerable situations
but also produce very vulnerable group of people who are exposed to all forms of hazards
including HIV/AIDS and xenophobia.
There has been no recent war in Lesotho but the Basotho wars in the 19 th century made Lesotho
to lose much arable land to the Free Staters (Tylden, 1950:13-20). This has resulted in the
general lack of arable land in Lesotho and is partly responsible for the food insecurity in
Lesotho. Food insecurity is documented as one of the drivers of HIV/AIDS in Lesotho (GOL,
2006: x).
Decline in soil productivity
Many factors can contribute to decline in soil productivity. Some of the factors that have caused
a decline in soil productivity in Lesotho include poor farming methods, soil erosion, high
34
population pressure on the land, overgrazing and the use of inappropriate technology in farming.
Decline in soil productivity leads to a fall in food production and this can affect people‟s food
needs and their immune system. People with weak immune systems are more vulnerable to
HIV/AIDS (MOHSW, 2008:14).
The dynamic pressures explained above translated the root causes discussed under sub section
2.1.1 into unsafe conditions. A look at some of the unsafe conditions in Lesotho is explained in
the next sub section.
2.2.3 Unsafe conditions
Unsafe conditions are the specific forms in which the population‟s vulnerability is expressed in
time and space in conjunction with the hazard (Twiggs, 2001:5). Unsafe conditions also include
lack of protection by the state, engaging in dangerous livelihood such as prostitution with its
attendant health risk of HIV/AIDS, low income levels and its uneven distribution, lack of
disaster preparedness and prevalence of endemic diseases (Wisner et al. 2004:51, 55).
Risky behaviours and practices
Risky behaviours and practices such as prostitution and casual sex practices, drug and alcohol
abuse, the practice of multiple sex partners and even the use of same razor blade to circumcise
many initiates in the traditional initiation schools are some of the practices that create very
unsafe condition in the face of HIV/AIDS in Lesotho (GOL, 2006:43).
False claims and beliefs
False claims and beliefs such as, HIV virus is found in condoms, having sex with a virgin cures
AIDS, traditional doctors have a cure for AIDS or that AIDS is a “slim” disease, all create unsafe
conditions. The belief that HIV/AIDS was imported into Lesotho by foreigners generates
xenophobic tendencies which does not only create unsafe conditions for the people but is a
serious hazard by its own merit.
35
Discrimination and stigmatization
Discrimination occurs when a distinction is made against a person that results in his or her being
treated unfairly and unjustly on the basis of their belonging or perceived to belong to a particular
group while stigma is a process whereby an individual is significantly discredited in the eyes of
others (UNAIDS, 2002:8, 10). In the case of HIV/AIDS, stigma may be as a result of shame and
fear.
Shame because sex which is the main route of HIV transmission in Lesotho (UNDP, 207:46) is
still surrounded by taboo and moral judgment and fear because HIV/AIDS is relatively new and
considered deadly (UNAIDS, 2002:7).
Discrimination and stigmatization of people living with HIV/AIDS (PLWHA), remains one of
the prominent unsafe condition facing many societies that are implicated with the effects of
HIV/AIDS. These two problems are cited by almost every researcher on HIV/AIDS (Whiteside,
2008:4, 9, 112; ILO/USDOL, 2005; UNGASS, 2008). Stigma, silence, discrimination, denial and
lack of confidence undermine prevention, care and treatment efforts. Thus the impact of
HIV/AIDS on individuals, families, communities and nations is increased (United Nations
Declaration of Commitment on HIV/AIDS in UNAIDS, 2002:6). Discrimination in job
opportunities and other social networking has forced many people not to go for HIV testing or
not to disclose their HIV status. Stigmatisation is also another unsafe condition in Lesotho for
PLWHA since many people associate being HIV positive to being sexually promiscuous (Moeti,
2007:4). Despite efforts from HIV/AIDS role players to eradicate stigmatisation and
discrimination against PLWHA, the practice seems to continue unabated in Lesotho and the
situation presents very unsafe conditions especially for PLWHA.
Heavy reliance on foreign aid
The country also heavily relies on foreign aid and most people especially in the mountain areas
have developed the culture of depending on foreign food and relief supply even during normal
situations. Food crisis forced the Lesotho government to declare a state of emergency in April
2002 and then again in February 2004 (LVAC, 2004:5). NGOs like World Vision, CARE
International, the Lesotho Red Cross Society and United Nations agencies like the World Food
Programme (WFP), Food and Agricultural Organisation (FAO) and others are very active in
36
Lesotho in the domain of food relief. This culture of dependence impedes local community
participation in their economic development, does not build resilience and it is not sustainable.
An average Lesotho peasant farmer also relies on the government to supply him or her with
farming inputs like seeds, fertilizer and even tractors to plough the fields.
Coupled with poor farming practices and isolated small farm plots, Lesotho is very vulnerable in
her food supply. There is therefore heavy reliance on RSA for basic commodities and in a
situation of serious differences between the two countries like the disagreement in 1998 Lesotho
will be in serious trouble.
Fragile institutions
The newly created Lesotho Disaster Management Authority (DMA) in 1997 has not yet been
well equipped with both personnel and equipment to handle disaster of even average magnitude.
This lack of capacity creates unsafe conditions in the face of external shocks or hazards.
Although HIV/AIDS was declared a national disaster in 2000 (GOL, 2006:2), HIV/AIDS may
not be managed as other disasters with the serious involvement of the DMA. Effective education,
training and information dissemination on matters related to disasters are generally lacking in
Lesotho. Despite mass education and awareness campaigns on HIV/AIDS in Lesotho, the
majority of the Basotho have not made any significant change in their sexual practices of having
multiple and concurrent unprotected sexual relationships (GOL, 2004:17).This type of attitude is
one of the main drivers of HIV/AIDS in Lesotho. Besides, the government responded late to
HIV/AIDS (Kimaryo et al. 2004:19), and it is only recently that the government started
integrating disaster risk reduction into her national development programmes.
2.3 LINKING THE PAR MODEL, DISASTER RISK REDUCTION AND THE IMPACT OF
HIV/AIDS IN LESOTHO
Disaster risk reduction basically involves tackling the causes of hazard events (like HIV/AIDS)
by putting in place preparedness, mitigation and prevention measures as well as reducing
vulnerability and building coping capacity/resilience within the community and integrating all
these in the long term and sustainable development plans (DFID, 2006:9-10). The above
statement can be summed in the risk equation.
37
2.3.1 The risk equation and HIV/AIDS in Lesotho
The risk equation is very important in disaster risk reduction. This is because the risk that may
result into a disaster (like the case of HIV/AIDS in Lesotho) is a function of the hazard and the
degree of vulnerability of the society to the impact of that hazard.
The impact of the hazard on the vulnerable society is worse if that society lacks coping capacity
or resilience. Though there are some variants in the elements of the risk equation, the equation
used by the United Nations International Strategy on Disaster Reduction is very popular and it is
used for the purpose of this research.
RISK (R) = HAZARD (H) X VULNERABILTY (V)
CAPACITY(C)
This equation can be used to factor in the impact of HIV/AIDS. The risk(R) of loss of lives and
other socio-economic damages as a result of HIV/AIDS are very high in Lesotho because
HIV/AIDS (H) intensity measured by the prevalence rate (23.2%) is high, exposure and spatial
coverage is wide (national) and there are many root causes that have been translated into unsafe
conditions by several dynamic pressures (V).The result is that the impact of the hazard
overwhelmed the resources and coping capacity of Lesotho such that HIV/AIDS became a
disaster and was consequently declared a national disaster in 2000.
The hazard component of the risk equation above can be reduced by putting in place
preparedness, prevention and mitigation strategies as well as actions that aim at minimizing
exposure to the hazard (DFID, 2006:9). Meanwhile vulnerability can be reduced by carrying out
a vulnerability assessment (not covered in this research) and applying the Progression of Safety
Model (Wisner et al. 2004:343) The later involves addressing root causes of vulnerability,
reducing dynamic pressures and achieving safe conditions (Wisner et al. 2004:344).
This will help to build a more resilient Lesotho with enough coping capacity that will enable
Lesotho to withstand external shocks and therefore avoid disasters such as the current HIV/AIDS
situation.
There is a model in demography (the Demographic Transition Model), that can be used for the
purpose of this research to compliment the PAR Model. The relation is established by the fact
38
that the PAR Model is used to explain the progression of vulnerability to the impact of
HIV/AIDS while the Demographic Transition Model is used to explain the changes the impact of
HIV/AIDS has made on the demographic trajectory of Lesotho. Besides complimenting the PAR
model, the incorporation of the Demographic Transition Model in this research can be used to
demonstrate the cross-cutting and inter-disciplinary nature of disaster risk management. The next
sub section takes a closer look at the Demographic Transition Model.
2.4 THE DEMOGRAPHIC TRANSITION MODEL AND HIV/AIDS IN LESOTHO
The Demographic Transition Model (DTM) was developed in the early 20 th century and
basically the DTM provides a general description of the changes in the death rates and birth rates
that occurred in developed countries since the 18th century (Nicolau, 2006:61). The relevance of
the DTM to the study of the demographic impact of HIV/AIDS in Lesotho is to shade more light
on the effects of HIV/AIDS on the demographic trajectory of Lesotho.
2.4.1 The precepts of the Demographic Transition Model
The Demographic Transition Model (DTM) explains the transformation of the developed
countries from high birth rates and high death rates to low birth rates and low death rates as part
of the economic development of these countries (Wikipedia, 2007:1). The idea started in 1929
with Warren Thompson, an American demographer who gathered data from certain counties
between 1908 and 1927 and divided these countries into group A, group B and group C based on
their demographic characteristics (Weeks, 2005:91). Later in 1945, Frank Notestein described
these groups as “Incipient Decline”, “Transitional Growth” and “High Growth Potential”
respectively (Weeks, 2005:90-96). Miller (2000:271) in (Nicolau, 2006:61) describes the three
stages as Pre-industrial, Industrial and Post industrial stages. In the same year in 1945, Davis
used the word “Population Explosion” to describe countries in the transitional growth stage of
Frank Notestein (Weeks, 2005:91).
The demographic transition is based on the concept of modernization where modern societies are
said to be characterized by low birth and death rates while traditional societies have high birth
and death rates, and between these two societies is the demographic transition (Weeks, 2005:92).
39
Other concepts closely associated with modernization are “Westernisation”, “Industrialisation”
and Secularisation (Weeks, 2005:94). These later concepts have themselves been strongly
criticized by many scholars, notably Karl Marx and so has the DTM been critcised and changed
(Weeks, 2005:93-96). Despite these criticisms and changes, the researcher finds a lot of
relevance in the propositions of DTM in relation to the demographic impact of HIV/AIDS in
Lesotho.
The DTM has many stages and there seems to be no agreement as to the exact number of stages
the DTM should have. For example there is DTM with four stages (Miller, 2000: 271) in
(Nicolau, 2006:61), there is three stages DTM (Weeks, 2005:92) while Geography All the Way
(see Figure 2.3) depicts five stages. The later is more comprehensive and is reproduced below.
The DTM is even said to comprise of a series of transitions such as the mortality transition,
fertility transition, migration transition, age transition, urban transition and family and household
transition (Weeks, 2005:99-103). This researcher is of the opinion that the DTM should also
include the HIV/AIDS transition since HIV/AIDS seems to affect fertility, mortality, migration,
families and households in highly affected countries like Lesotho.
40
Figure 2.2 The Demographic Transition Model
Source: Geography All the Way [s.a.]
Besides the reasons stated in the diagram above, many other reasons were advanced to explain
the fall in fertility in the industrialized societies. Prominent among them were the ideas that
secularization, industrial development, modernization, westernization, mass education and
similarity in culture helped to reduce birth rates in developed countries. This thinking was
spearheaded by Ansley Coale and J. Wiiliams in the 1960s (Weeks, 2005:95). The Rational
Choice Theory of Coleman and Feraro in 1992, was centered on cost/benefit analysis on child
bearing decisions while Caldwell expanded on the Rational Choice Theory by propounding the
“Wealth Flow Theory” to explain why more children were desired in traditional societies than in
modern societies.
41
The “Demographic Change and Response Theory” by Kingsley Davis is another line of
argument which explains how fall in mortality in modern societies invariably led to fall in
fertility as family resources became scarcer among the survivors. The “Relative Cohort Size
Hypothesis” by Easterlin centered on the perception of a particular population cohort on their
future income and standard of living (Weeks, 2005:98). A perception of lower standard of living
meant the desire to have fewer children (Weeks, 2005:98 and 99). All these reasons are advanced
to explain why birth rates fell in developed countries. In the same vein, a couple of reasons were
used to explain the fall in death rates in developed countries. A few of these reasons are stated
below.
Fall in death rates were associated with higher and better food production and distribution due to
better production technology and improvement in transportation (Weeks, 2005:100). Besides,
importation of better medical technology from the industrialized countries benefited the
developing countries and led to fall in mortality rates. Also, better personal hygiene and
sanitation contributed to fall in death rates (PRB, 2007). The next paragraphs look at the
relevance of the DTM to this research.
2.4.2 Application of the DTM to the demographic impact of HIV/AIDS in Lesotho
Looking at the characteristics of each stage in the DTM, the researcher is of the opinion that
most developed countries are in the stage of late expanding, low stationary or declining stage of
the DTM while most developing countries including those in sub Saharan Africa were mostly in
early expanding or late expanding stage before the advent of HIV/AIDS. Lesotho in particular
was somewhere around the early expanding stage in the 1990s but recent demographic
characteristics point to the fact that fertility rates have fallen, mortality rate has been rising and
the total population has dropped from 2.3 million in 2003 to 1.8 million in 2006 (BOS, 2007:2).
The researcher therefore suggests that HIV/AIDS need to be factored into this theory of the
DTM if it stands any chance of relevance or to be applied in sub Saharan Africa countries at the
moment where HIV/AIDS is very high. Probably HIV/AIDS has halted and reversed the
demographic transition of Lesotho and possibly those of other sub Saharan Africa countries
which are highly affected by HIV/AIDS.
42
The new position of these countries in the demographic transition theory needs to be redefined
or an entirely new demographic transition theory needs to be formulated for sub Saharan Africa
and this can be done in a further research.
2.5 SUMMARY
The pressure and release (PAR) Model is used to explain the progression of vulnerability to the
impact of HIV/AIDS in Lesotho. The PAR Model shows how a society like Lesotho can face
pressure as a result of the progression in vulnerability on the one side (when dynamic pressures
translate root causes into unsafe conditions) and pressure from a hazard or hazards (influenced
by the nature of the hazard, its intensity and exposure). Such opposing pressures can overwhelm
the coping capacity of the society and result in a disaster like the case of HIV/AIDS in Lesotho.
The PAR Model is then used to explain the demographic impact of HIV/AIDS in Lesotho.
However, to compliment and further demonstrate the demographic impact of HIV/AIDS in
Lesotho, a model in demography is incorporated into the study. The Demographic Transition
Model which shows how countries, especially developed countries progressed in stages in their
demographic trajectory over time is used to explain the impact of HIV/AIDS on the demographic
trajectory of Lesotho. The two models therefore not only help in a fuller and better understanding
of the demographic impact of HIV/AIDS in Lesotho but also advance the knowledge and
understanding that disaster risk reduction within which context the research is carried out is a
cross-cutting and an inter-disciplinary science.
43
CHAPTER THREE
LITERATURE REVIEW ON THE PHENOMENON OF HIV/AIDS
3.1 INTRODUCTION
A lot of studies have been carried out and much has been written on HIV/AIDS such that an
exhaustive review of related literature on HIV/AIDS will be impossible. The number of articles
written on HIV/AIDS, the amount of electronic material from the internet on HIV/AIDS, reports
from international, regional and national conferences on HIV/AIDS, publications from
international organisations like the Joint United Nations Programme on HIV/AIDS (UNAIDS),
World Food Programme (WHO), World Bank, United Nations Development Programme
(UNDP), United Nations Fund for Population Activities (UNFPA) to name but a few cannot be
exhausted in a literature review on HIV/AIDS. Besides published books, research findings from
individual researchers, publications from government departments and specialised organs which
deal specifically with HIV/AIDS, journals, Acts and policies on the same topic abound. In fact
the list of sources on HIV/AIDS seems inexhaustible.
Despite these myriad of sources, there is still information gap and lack of data (may be for
specific use) which poses a constraint in the understanding of the past, current and future effects
of HIV/AIDS (Whiteside, 2008:55). There is still much research and information gap on the
impact of HIV/AIDS in Lesotho and studies on this topic are scattered and not well documented
(Moeti, 2007:1, 23). For example the Lesotho AIDS Programme Coordinating Authority was
established in 2001 and its successor, the National AIDS Commission (NAC) was created in
2005 with the broad mandate to monitor and coordinate activities related and relevant to
HIV/AIDS and STIs, disseminate information in order to prevent and control the spread of
HIV/AIDS in Lesotho. Unfortunately, there is lack of comprehensive historical data on the
impact of HIV/AIDS since the first case was reported in 1986 (Moeti, 2007:24).
By investigating the demographic impact of HIV/AIDS in Lesotho over a given period of time,
this research can help close the information lacuna mentioned above.
This chapter explores related literature to the research theme as part of the literature review. The
approach is to first indicate the data sources and then give a brief historical background of
44
HIV/AIDS. This is followed by five other sub sections which are relevant to the research
problem and the research questions. In each sub section, the literature review flows in the form
of an overturned triangle, that is from general to specific. It starts with a study of the global
HIV/AIDS situation (with emphasis on Africa and particularly southern Africa as a sub region)
and then the literature review narrows down to Lesotho, which is the focus area of this research.
Effort is made as much as possible to use only recent documents on HIV/AIDS.
3.2 A BRIEF HISTORICAL BACKGROUND OF HIV/AIDS
Although the first cases of HIV/AIDS probably occurred in the 1930s, AIDS was publicly
reported on the 05 January 1981 in the Morbidity and Mortality Weekly Report produced by the
Centre for Disease Control (CDC) in Atlanta in the USA and the name AIDS was agreed upon in
Washington in July 1982 (Whiteside, 2008:1, 2).
Following intensive scientific research especially in France and the USA, it was discovered that
AIDS is caused by a virus and in 1987, the name Human Immunodeficiency Virus (HIV) was
confirmed by the International Committee on Taxonomy of viruses as the name of the virus that
causes AIDS (Whiteside, 2008:2). Since this period, different countries reported their first
HIV/AIDS cases on different dates and the number of new cases has not seized to grow till
today.
HIV/AIDS grew to become a biological disaster in many sub Saharan Africa countries but until
recently did not receive the same international attention as other natural disasters (Wisner, 2004).
When HIV/AIDS caught international attention in the 1980s, it was treated mainly as a health
and medical problem (Moeti, 2007:2). The social dimensions of HIV/AIDS was somehow
neglected despite the fact that findings from social science research do have an important role to
play in establishing an appropriate mix of medical and behavioural intervention strategies in
combating HIV/AIDS at the most effective geographical scale. A recent change in paradigm has
led to a rapidly growing academic literature on the social science of HIV/AIDS especially in
southern
Africa
with
contributions
from
economists,
demographers,
sociologists,
anthropologists, educationists, as well as geographers (Moeti, 2007:2). This research adds to the
45
contribution from the social and human sciences in the understanding and managing of HIV/
AIDS as a disaster. The research investigates the progression of vulnerability as a socioeconomic backdrop to study the demographic impact of HIV/AIDS within the disaster
management discipline and does not investigate HIV/AIDS from a medical point of view.
3.3 HIV/AIDS: THE GLOBAL SITUATION
Four parameters were used in this section to review the global demographic effects of
HIV/AIDS. These parameters included the prevalence rate, the mortality rate, life expectancy
and gender and age differential effects. HIV prevalence and incidence are two parameters which
are important in the study of HIV/AIDS (Whiteside, 2008:15). While the HIV prevalence is the
absolute number of people infected, the prevalence rate is the proportion of the population
infected at a particular time. The former is always given as a percentage of a specific segment of
the population (Whiteside, 2008:15). HIV incidence on the other hand is the number of new
infections over a given period of time while the incident rate is the number of infections per
specific unit of population, say 1,000 or 10,000 per period of time. The later is often expensive
and complex to measure, so the former is widely used (Whiteside, 2008:15). In this research, the
HIV prevalence rate will be used. Another parameter that will be used is the crude death rate and
its effects on life expectancy (see 1.9.2) as well as gender and age differential effects of
HIV/AIDS to highlight the degree of vulnerability of different demographic groups.
3.3.1 Global HIV prevalence rates
The global HIV prevalence situation is studied from the world situation, then the situation in sub
Sahara Africa followed by the situation in southern Africa and lastly the HIV prevalence rate by
gender.
In 2006, after twenty-five years since AIDS was discovered, about 40 million people in the
world were living with HIV (Whiteside, 2008:4). This estimate is close to that quoted by the
UNAIDS/WHO (2007:1-6) which estimated that 39.5 million people in the world were living
with HIV in 2006 up from about 8 million in 1990. The figure reduced to 33.2 million people in
2007. Of the 33.2 million people, 30.8 million were adults between the ages of 19-49 and
46
children below 15 years accounted for 2.4 million. The total number of people living with
HIV/AIDS increased more than 400% between 1990 and 2007 as shown in Figure 3.1
Figure 3.1: Global number of people living with HIV (1990-2007)
Source: UNAIDS/WHO, 2007:4
Globally, the number of children under 15 years living with HIV increased from 1.6 million in
2001 to 2.0 million in 2007 with about 90% of them found in sub-Saharan Africa (UNAIDS,
2008:9). These figures point to the fact that HIV/AIDS is predominantly a sub Saharan Africa
disease and the most vulnerable population is also the active population, alongside women and
children.
There was a 16% drop in the global number of people living with HIV between 2006 and 2007,
and 70% of this reduction was accounted in six countries which included, Angola, India, Kenya,
Mozambique, Nigeria and Zimbabwe which all reported a reduction in risky behaviour among
their populations (UNAIDS/WHO,2007:3). Unprotected sex especially during the state of
drunkenness is one such risky behaviour that can be a fuelling factor in the spread of HIV/AIDS.
Meanwhile the drop in annual infection rate since 2002 was mainly due to improved services in
the prevention of mother-to-child transmission (UNAIDS, 2008:9).
47
Though HIV prevalence stabilised since 2001, it is doing so at an unacceptable high level. In
2007 alone, 2.5 million people were newly infected with the HIV virus, 2.1 million of whom
were adults and 420,000 children below 15 years (UNAIDS/WHO, 2007:6 and 7). More research
is needed on how to bring down these figures.
HIV prevalence rates in sub Sahara Africa
Sub Sahara Africa remains the most seriously affected region in the world and AIDS remains the
leading cause of death in this region (UNAIDS/WHO, 2007:4). Sub Sahara Africa represents
only 11% of the world estimated 6.7 billion people in 2008 (PRB, 2008:5) but accounted for
more than 68% of all those living with HIV/AIDS and 76% AIDS deaths (UNAIDS/WHO,
2007: 6 and7). The total number of people living with HIV in sub-Saharan Africa rose from 20.9
million people in 2001 to 22.5 million in 2007 though new infections fell from 2.2 million to 1.7
million within the same time (UNAIDS/WHO, 2007:7 and 8). The prevalence rate is higher in
urban areas and HIV/AIDS is a major crisis for African cities (Pelling and Wisner, 2009:31)
Situation in southern Africa
Southern Africa had 35% of all people living with HIV, 32% of the global AIDS deaths and 32%
of the total new infections in 2007 (UNAIDS/WHO, 2007:15). In this sub region prevalence
rates have either reached or are approaching a plateau (except for Mozambique) but are still very
high by world standards. Ten leading countries with a prevalence rate of more than 15% (in
2005) were in southern Africa and they included: Swaziland (33.4%), Botswana (24.1%),
Lesotho (23.2%), Zimbabwe (20.1%), Republic of South Africa (18.8%), Zambia (17.0%),
Namibia (17.0%) as well as Mozambique (UNAIDS/WHO, 2007:11). One can therefore suggest
with a high degree of certainty that HIV/AIDS is dominantly a sub Sahara Africa disease with its
epicentre in southern Africa.
HIV prevalence rate by sex
HIV prevalence also shows sex disparity. Though the global ratio of HIV infection between men
and women has remained fairly stable, the total number of women living with HIV/AIDS rose
from 13 million in 2001 to 15.4 million in 2007 while that of men increased from 13.7 million to
48
15.4 million within the same period ((UNAIDS/WHO, 2007:8). In sub-Saharan Africa, 61% of
adults living with HIV in 2007 were women, compared to 43% in the Caribbean, 26% in eastern
Europe and 29% in Asia (UNAIDS/WHO, 2007:8). This disparity is shown graphically in Figure
3.2
Figure 3.2: Percentage of adults (15+) living with HIV who is female 1990-2007
Source: UNAIDS/WHO, 2007:9
It is not very clear what makes the sub Saharan Africa women more vulnerable than their Latin
America or Caribbean counterparts. However cultural values and practices could play a role in
this disparity.
3.3.2 Global AIDS deaths and the effects on life expectancy
By 2006, an estimated 20 million people in the world had died of HIV/AIDS (Whiteside,
2008:4). Global AIDS deaths ranged from about half a million in 1990 to more than 2 million in
2005 (see figure 3.3). In 2007 alone, 2.1 million people died of AIDS, out of which 1.7 million
people were adults and 330,000 were children below the age of 15 years (UNAIDS/WHO,
2007:6-9). The same source states that an estimated 5700 people die each day from AIDS and
most of these AIDS deaths (76%) occur in sub Saharan Africa (UNAIDS/WHO,2007:6-9). The
World Health Organisation in Whiteside (2008:21) estimates that in 2015, AIDS will still cause
one in six deaths in Africa.
49
Figure 3.3: Estimated number of adults and child deaths due to AIDS globally, 1990-2007
Source: UNAIDS/WHO, 2007:5
The demography of AIDS deaths also shows some disparity by population groups. Most affected
are the active age group between the ages of 20-49, women, young girls and children (Whiteside,
2008:56). This disparity will therefore affect the population structure of most highly affected
countries.
The sex ratio will be affected by the differential AIDS deaths. For example in the next twenty
years in many countries, men between the ages of 35 and 54 will outnumber women and this will
motivate men to look for younger sex partners thus perpetuating the vicious cycle of HIV
transmission over generations (Whiteside, 2008:65). Inter-generation sex is one of the factors
fuelling the spread of HIV/AIDS.
UNAIDS estimated that 320,000 AIDS deaths occurred in South Africa in 2005, 220,000 in
Nigeria and 180,000 in Zimbabwe in the same year (Whiteside, 2008:61). With such a high
number of AIDS deaths, South Africa is estimated to lose 6 million people to AIDS by 2015 and
this will represent 13% of her estimated total population (Whiteside, 2008:61). This loss will be
three times the current population of Lesotho and Botswana and only a large scale natural
disaster or a sophisticated nuclear war could possibly cause such a calamity. The socio-economic
loss to the country can be overwhelming since the World Bank predicts a 1.2% reduction in
economic growth for a 20% HIV prevalence rate (Whiteside, 2008:68).
50
The effect of HIV/AIDS on child mortality is increasing. For example, studies carried out in 42
countries in sub Saharan Africa showed that AIDS accounted for 2% of below 5 years mortality
in 1990, 7.7% in 1999 and nearly 10% in 2002. Countries with high HIV prevalence rates like
Botswana, Zimbabwe and Namibia showed worse scenarios where the under five mortality due
to AIDS were 42.4%, 35.1% and 26.8% respectively in 1999 (IAVI, 2005:12). The situation can
not be very different in Lesotho.
HIV/AIDS has reduced the life expectancy of many countries in the world and the most affected
countries are those in sub Saharan Africa especially the southern African sub region (PRB,
2008:7 and 8). A cost-benefit analysis shows that every 10% improvement in life expectancy
results in an annual rise in economic growth of 0.3% to 0.4% points (Whiteside, 2008:79).
Therefore sub Saharan Africa should be incurring a high socio-economic loss to the impact of
HIV/AIDS. The table below shows the impact of HIV/AIDS on mortality and life expectancy in
the most affected area in the world.
Table 3.1: Estimated and projected impact of HIV/AIDS on life expectancy
Source: Whiteside, 2008:62
51
Though the names of the seven most affected countries are not mentioned in table 1, there is no
doubt that they are mainly countries in southern Africa including Lesotho. According to the table
above, people in a country like Lesotho which has an HIV prevalence rate of more than 20%
should be losing more than 29 years in life expectancy. This demographic loss can translate to a
huge economic loss for Lesotho in terms of goods and services that these dead people could have
produced within the 29 years lost.
3.4 HIV/AIDS SITUATION IN LESOTHO
This section examines the effects of HIV/AIDS on major demographic processes in Lesotho. It
begins with a time series examination of the HIV prevalence rate in Lesotho, followed by the
impact of HI/AIDS on mortality and fertility rates. The implications of HIV/AIDS on migration
are also examined and lastly there is a review on HIV/AIDS and vulnerable children in Lesotho.
3.4.1 HIV Prevalence Rates in Lesotho
Since the first case of HIV was reported in Lesotho in 1986, the prevalence rate has not seized to
increase (UNDP, 2007:47). It was only 2% in 1992, then shot to 21% in 2000, 31% in 2002
before falling and stabilizing at 23.2% between 2005 and 2007 (GOL, 2006:3; UNAIDS,
2008:5). Since 2005 the adult HIV prevalence rate has not changed (UNGASS, 2007:5). The
current HIV prevalence rate of 23.2% makes Lesotho the third highest infected country in the
world following Swaziland and Botswana (UNAIDS/WHO, 2007:11). This position is up from
the fourth position in 2002, when Lesotho was behind Swaziland, Botswana and the Republic of
South Africa. By the end of 2007, 270,273 people were living with HIV in Lesotho, out of
which, 11,801 were children and 258,472 were adults and about 62 new HIV infections occurred
each day in 2007 (UNGASS, 2008:15). These figures could be considered as indicative figures
and not absolute figures but the figures paint a picture of the HIV/AIDS situation in Lesotho.
HIV prevalence rates are generally higher in urban areas than in rural areas in Lesotho (see
figure 3.4).
52
07
20
05
20
03
20
01
20
99
19
97
19
95
19
93
Urban
Rural
19
19
91
%
40
35
30
25
20
15
10
5
0
Figure 3.4: Rural/Urban HIV Prevalence Rate over time in Lesotho
Source: MOHSW, 2008:16
In 2004, the rural-urban HIV/AIDS prevalence rate was 21.9% and 29.1% respectively
(MOHSW, 2005:235) and in 2007, it was 22.2 and 31.1% respectively (MOHSW, 2008:16).
Rural-to-urban migration and high unemployment rates in urban areas were partially responsible
for this disparity (UNGASS, 2008). Major highways, busy border towns and project
development sites like road and dam constructions were also identified as having higher than
average HIV prevalence rates (Kimaryo et al. 2004:68; Whiteside, 2008:13). These areas could
be termed the HIV/AIDS hot spots and the possible reasons could be that there is much
interaction among people from different walks of life as well as having people with higher
disposable income to pay for commercial sex.
The HIV prevalence rate also varies by district from as low as 20% in Mokhotlong and ThabaTseka to over 30% in Leribe and Maseru (GOL, 2006:3). These disparities can be attributed to
factors such as high population mobility, access to highways, and proximity to busy urban areas,
rural-urban migration and adequacy of surveillance systems in place (GOL, 2006:3). There is
therefore some degree of correlation between HIV/AIDS prevalence rate and extent of
urbanization of the area or district in Lesotho as shown in figure 3.5.
53
HIV PREVALENCE BY DISTRICT PREVALENCE
40
35.8
% PREVALENCE
35
30.5
30
28
27.9
25.7
23
25
20
15.5
15.1
15
10
5
E
K
A
G
A
A
B
T
H
Q
U
T
S
T
H
N
T
LO
O
H
O
K
M
A
LE
M
O
H
IN
G
E
K
'S
A
H
S
E
O
R
U
G
M
A
F
E
T
E
N
IB
E
M
LE
R
B
E
R
E
A
0
DIST RICT NAME
Figure 3.5: HIV Prevalence Rate by District in 2007 in Lesotho
Source: MOHSW, 2008:15
Prevalence rates also show gender differences in Lesotho. More women and girls are affected by
HIV/AIDS in Lesotho than men and boys (Phamotse, 2008:3). In 2002, about 180,000 (55%) of
the estimated 330,000 adults living with HIV/AIDS were women and also 55% of the 4000 new
cases reported in 2001 were women (UNAIDS, 2003) in (Kimaryo et al. 2004:69). In 2007, out
of 258,472 adults living with HIV, 153,581 were women compared to 116,692 who were men
(UNGASS, 2008:5). These figures point to the fact that women are more affected by HIV/AIDS
than men and therefore confirms the fact that women are more vulnerable to HIV/AIDS.
HIV/AIDS prevalence by age points to the fact that the active population and children are at high
risk. One out of three Basotho infected with HIV fall between the age of 15-49 years and 27,000
children between the ages of 0-14 years were living with HIV/AIDS in 2002 while nearly 10% of
all the newly reported HIV/AIDS cases in 2001 were children below the age of 4 years who got
the virus through mother-to-child transmission (MTCT) of the disease (Kimaryo et al. 2004:69).
This calls for improved services to reduce MTCT in Lesotho.
Most sources consulted (GOL, 2006; MOHSW, 2008; UNAIDS/WHO, 2008;UNGASS, 2008)
show that the population groups at high risk of infection include children through MTCT, girls,
women, youth, migrant workers, and people already infected with sexually transmitted infections
(STI). Meanwhile occupations more at risk include, drivers, mine workers, police, soldiers, sex
workers and teachers (Kimaryo et al. 2004:69-70). These age groups and occupations therefore
54
constitute the HIV/AIDS epidemic hot spots and should be the focus for the fight against
HIV/AIDS
3.4.2 Impact of HIV/AIDS on the Mortality Rate and Life Expectancy
The direct demographic impact of HIV/AIDS is that it increases the morbidity and mortality
rates and reduces life expectancy (Barnett and Whiteside, 2006:180; Whiteside, 2008:56).
HIV/AIDS is a chronic debilitating disease which ultimately leads to the untimely death of the
economically productive population (GOL, 2006:10). In a very youthful population like that of
Lesotho, increase in mortality rate exacerbates the already high dependency ratio (PRB,
2008:11). In Lesotho, morbidity and mortality due to AIDS has caused unprecedented impact on
the general population (MOHSW, 2008:5) and the HIV/AIDS pandemic has reached crisis
proportion despite efforts put in place by the government (Kimaryo et al. 2004:20). This
statement points to the fact that strategies and policies adopted so far in the country to upscale
the impact of HIV/AIDS need to be over hauled. Realignment of strategies and policies to
combat HIV/AIDS in Lesotho are discussed in the last chapter. The next sub section looks at
mortality rate in detail.
The Crude Death Rate
The crude death rate in Lesotho was 11.7 per thousand in 1986, then climbed to 12.8 by 1996
while the Lesotho Demographic and Housing Survey (LDHS) of 2004 indicated an adult
mortality rate of 11.09 per thousand (BOS,2005:2) but in 2007 the national mortality rate was 25
per thousand (PRB, 2008:8). This sharp increase in mortality given by two different sources
could mean some sources either under report the mortality impact of HIV/AIDS while others
exaggerate the impact. The two figures could also mean that many HIV/AIDS infected people in
Lesotho started dying in huge numbers between 2004 and 2007. About 70 people die each day in
Lesotho from AIDS-related illness (Kimaryo et al. 2004:20). If this figure is multiplied by a
minimum of 365 days for a normal calendar year, then Lesotho should be losing about 25,480
people to AIDS related illness. This can be a huge loss in human capital to a small country like
Lesotho.
55
The Infant Mortality Rate
In 2004, the infant mortality rate was 91 per thousand up from 81 per thousand reported in the
2001 survey, child mortality was 24 per thousand down from 35 per thousand and under five
mortality rate remained the same at 113 per thousand within the same study period (BOS,
2005:115). Besides HIV/AIDS, socio-economic characteristics such as education level inversely
influenced the degree of vulnerability to child loss in Lesotho (MOHSW, 2008:17-19). So again
caution should be taken to differentiate natural demographic trends and the impacts due to
HIV/AIDS since the entire changes in infant mortality rate can not be blamed on HIV/AIDS.
Malnutrition is a serious problem in Lesotho and can be a major cause of infant and child
mortality in the country.
The Maternal Mortality Ratio
Maternal mortality ratio was 762 per 100,000 live births in 2004 and this showed an up surge
from the 419 per 100,000 reported in 2001 (BOS, 2005:266). This source strongly attributes the
increase in maternal mortality in Lesotho to the increase in HIV/AIDS prevalence rate especially
among young women since the mid 1980s. Other possible factors that might increase the
maternal mortality as well as the total mortality in Lesotho could include poverty, malnutrition
due to food shortages, rising unemployment rates, retrenchment of thousands of Basotho mine
workers and the general slow down in the domestic economy (GOL, 2006:x)
HIV/AIDS was mentioned in almost all the sources consulted as having considerable impact on
mortality rate in Lesotho but the snap-shot data on AIDS related mortality, disparity in reporting
from different sources and sometimes the lack of specific mortality figures made the study of the
demographic impacts of HIV/AIDS unclear and confusing. Besides, there is always a time lag of
about five to even fifteen years between HIV infection and AIDS-related illness and subsequent
death (UNAIDS, 2008:2). Therefore mortality rates can be expected to rise significantly and life
expectancy to fall even further over the coming years in Lesotho when the currently infected
people will fall ill and later die.
56
The Life Expectancy
The Lesotho demographic survey of 2001 showed that the life expectancy in Lesotho fell from
58.6 years in 1996 to 48.7 years in 2001 for men and from 60.2 years in 1996 to 56.3 years for
women in the same period (BOS, 2002). In 2007, the life expectancy in Lesotho was reported to
have fallen to 35 years and 36 years for male and female respectively (UNAIDS/WHO,
2007:11). This researcher suggests that the increasing death rate and the falling life expectancy
in Lesotho can be strongly but not entirely attributed to the impact of HIV/AIDS. Other diseases,
famine and even general economic hardship observed in the country can increase death rate. The
next section looks at the overall effects of HIV/AIDS on fertility
3.4.3 The impact of HIV/AIDS on Fertility Rate
Pregnancy and child bearing starts early in Lesotho where one in eight girls aged 15-19, one in
two aged 20-24 and three in four aged 25-29 years have been pregnant and this ratio is even
higher in rural areas (BOS, 2005:57-59). This indicates not only early sex debut but also high
level of unprotected sex practices which can both be favourable conditions for the spread of
HIV/AIDS.
Most literature on the effects of HIV/AIDS on fertility rate indicates that HIV/AIDS reduces the
total fertility rate (Moeti, 2007:16). In Lesotho, the total fertility rate dropped from 5.4 children
in 1976 to 3.5 children in 2004 (MOHSW, 2008:6).
Although this drop may not be entirely attributed to the effects of HIV/AIDS, the later
nonetheless must have played a key role. A look at the crude birth rate in Lesotho showed a
similar downward trend. It dropped from 38 children per thousand in 1976 to 30 children per
thousand in 2006(BOS, 2007:3).
A couple of logical explanations have been advanced by various sources for this inverse
relationship between HIV/AIDS and fertility rate. First of all, and in the particular case of
Lesotho is the fact that women who bear children are disproportionately more infected than men
(Moeti, 2007:16; MOHSW, 2008:16). Besides, measures that have been put in place to upscale
the rate of HIV/AIDS infections and transmission, like the use of condoms, have to an extent
57
helped to reduce the rate of unwanted teenage pregnancies in Lesotho (ADF, 2007). Many
Basotho suffer from STI and the rate of STI has been increasing (MOHSW, 2008:26).
STIs not only increase the vulnerability of the patient to HIV/AIDS infection but also negatively
affect the fertility of the sufferer (WHO, 2007).The indicated fall in fertility can also be
attributed to other socio-economic factors besides the effects of HIV/AIDS. However, the later
not only reduces the fertility rate but also infects the fewer born babies and causes their
premature deaths. Thus, the number of children in the total population falls.
3.4.4 Impact of HIV/AIDS on Migration
Migration is one of the important factors that influence the growth or decline, as well as the
distribution of people over a given area per time. Migration could be divided broadly into
internal and international migration (Weeks, 2005:276).
Unlike natural disasters like floods, droughts, earthquakes, tsunamis or human induced disasters
like wars, chemical spills and other technological hazards, there is no clear and direct evidence
that suggest HIV/AIDS as a cause or a push factor for both internal and international migration.
HIV/AIDS is a biological hazard that has led to a biological disaster in Lesotho (GOL, 2006:2;
Wisner, 2004:188). In the cases of other natural and human induced disasters, people may be
forced to move either as internally displaced people (IDPs) or as refugees. In 2005, the total
number of IDPs in the world was 20,971,800 and that of refugees was 11,761,400(IFRC,
2006:229-235) However, a careful examination of migration indicates some implications with
HIV/AIDS. First, migrant workers are said to be an important factor in the spread of HIV/AIDS
(Moeti, 2007:24)
International migration can increase the vulnerability of the immigrants to HIV/AIDS infection
(Whiteside, 2008:50-51). This is because immigrants usually face difficult socio-economic
conditions in their host countries and this exposes them to risky behaviours such as commercial
sex, drug and alcohol abuse. These behaviours increase their chances of contracting HIV/AIDS
(ILO/USDOL, 2005). Besides, some people in certain countries especially in southern African
sub region, belief that HIV/AIDS was imported through immigrants or that immigrants coming
58
into South Africa come from countries that are HIV/AIDS hotspots (Barnett and Whiteside,
2006:164). These types of beliefs, whether right or wrong can fan sentiments of xenophobia,
another potential hazard that can lead to large scale disasters. The recent xenophobia attack on
foreigners in South Africa should be a clear warning and a wake up call to policy makers and
disaster managers of an impending human-induced disaster.
In Lesotho, mine workers who migrate to work in South Africa and only periodically return
home, have been identified as good vectors for the transmission and spread of HIV/AIDS in
Lesotho (Kimaryo et al. 2004:70). These sexually active migrants are most often separated from
their spouses and they live in single sex hostels at the mines (Kimaryo et al. 2004:70; Whiteside,
2008:50). This type of living arrangement not only encourages having multiple sex partners but
also encourages same sex practices with a higher chance of contracting HIV/AIDS (Barnett and
Whiteside, 2006:167). When these mine workers return home in Lesotho, they infect their
spouses with HIV (UNGASS, 2008:33). On the other side of the coin is the possibility that the
left behind spouses of these mine workers are likely to involve themselves in extra marital
affairs. This can increase their chances of being infected with HIV/AIDS and later on infect their
spouses.
Rural-urban migration is high in Lesotho and the rate of urbanisation is rapid (GOL, 2006:54;
BOS, 2007:4). The rural-to-urban migrants, who are mostly young girls, go to urban areas to
look for jobs especially in the garment industries (UNGASS, 2008:55). Unfortunately, many of
these migrants end up not having jobs and therefore resort in risky activities like paid sex, drug
and alcohol abuse and casual sex practices (UNGASS, 2008:33). These commercial sex workers,
“Likuena” as they are popularly referred to in Lesotho, are mostly young girls, some as young as
14 years. They are vulnerable not only to HIV/AIDS infection but to other abuses (ILO/USDOL,
2005:3 and 4). The researcher noticed that even some of those internal migrant girls who may be
fortunate to pick up jobs in the garment industries still indulge in paid or transactional sex as a
means of supplementing their low wages.
Although it may be argued that socio-economic factors like poverty, unemployment, particular
cultural practices and social norms increase the vulnerability of many people in Lesotho to
59
HIV/AIDS infection, a careful analysis of the situation can trace the root cause to rural-urban
migration. This point is explained further in the research under the conceptual application of the
PAR Model to the in Lesotho (see Chapter two).
The next sub section focuses on orphans and vulnerable children (OVC). The section starts with
a definition of OVC and later looks at the demography of the OVC in Lesotho. A comprehensive
study of OVC in Lesotho is not covered in the research.
3.4.5 HIV/AIDS Orphans and Vulnerable Children (OVC) in Lesotho
An orphan is generally a child below the age of 18 years who has lost one or both parents
(UNAIDS/UNICEF/USAIDS in Richter, Foster and Sherr.2006:21) while a vulnerable child is
an orphan or any other child below 18 years who:
i) Has been deserted or neglected by one or both parent to the extent that he/she has no means of
survival and as such is exposed to danger of abuse, exploitation and discrimination
ii) Has a chronically ill parent (regardless of whether the parent lives in the same household as
the child)
iii) Lives outside family care (i.e. lives in an institution or on the street)
iv) Is infected or affected by HIV/AIDS or other chronic disease
v) Has a disability
vi) Has been physically, psychologically or sexually abused
vii) Is involved in commercial sex
viii) Is involved in child labour
ix) Has a “challenging” behaviour (i.e. behaviour that keeps him/her in conflict with the law or
behaves in a manner that may harm him/her (UNGASS, 2008:42). In this research, only the
category of vulnerable children infected or affected by HIV/AIDS will be considered.
The impact of HIV/AIDS on children is complex and multifaceted, with a high and long term
social cost (UNAIDS/UNICEF, 2002:9). The number of AIDS orphans has increased
dramatically in sub Saharan Africa from less than 1 million in 1990 to about 12 million in 2005
(Whiteside, 2008:66; UNAIDS, 2008). Botswana has the highest percentage of AIDS orphans
(20%) but South Africa has the highest absolute number of AIDS orphans totalling 1.2 million
60
(Whiteside, 2008:66). UNICEF estimates that by 2010 there will be 142 million orphans in the
world, with 50 million in sub Saharan Africa, out of which 18.4 million (36.8%) will be AIDS
orphans (Whiteside, 2008:66).
In Lesotho, one in ten children (10%) between 0-14 years old lost one or both parents due to
HIV/AIDS and the total number of AIDS orphans estimated at over 70, 000 was expected to rise
significantly (Kimaryo et al. 2004:20). In 2007, the total number of AIDS orphans in Lesotho
was about 90,000 (UNOCHA, 2007:2). More than 20% of Basotho children are orphans and
HIV/AIDS is rendering many of them vulnerable (Phamotse, 2008:2). In 2006, a total of 977,000
OVC were identified in Lesotho and out of this number, 356,670 were out of school (ADF,
2007:4 and 5). Though these figures do not specify the number of AIDS orphans, this researcher
suggests that AIDS orphans should make up a considerable number of these OVC.
The OVC have many needs ranging from psychosocial, educational, health, material to physical
needs (Richter et al. 2006:9). AIDS orphaned children face more disadvantages than those
children orphaned by other causes (Whiteside, 2008:66; Richter et al. 2006:6). For instance,
AIDS orphans‟ parents are likely to die after prolonged illness during which time, family
resources are depleted for treatment and subsequent funeral expenses (Nattrass, 2002). Besides,
AIDS orphans are also likely to be double orphans as one HIV/AIDS infected parent is likely to
infect the other. Worse still is the fact that the majority of these AIDS orphans live with their
grandparents and the orphans are likely to face a “Second generation” of orphaning when the
elderly caregivers also die shortly afterwards (Whiteside, 2008:66). Children impacted by
HIV/AIDS are at risk of exploitation, physical and sexual abuse. The later may even lead to the
perpetuation of the HIV/AIDS cycle through infection by the abuser or even by the abused. The
researcher therefore feels that HIV/AIDS contributes in no small way to the total number and
misery of OVC in Lesotho. The effects (such as the psycho-social effects) of HIV/AIDS on OVC
in Lesotho can be investigated in another research while the estimated number of AIDS orphans
in Lesotho is shown in the diagram below
61
Figure 3.6: Estimated number of AIDS orphans from 1994-2012 in Lesotho
Source: UNGASS, 2008:43
The graph above shows that there are many AIDS orphans in Lesotho and though the number is
somehow stabilising since 2008, it is none the less very high for a country like Lesotho. The
trend in the number of orphans in Lesotho in the coming years needs to be monitored in
subsequent research.
3.4.6 The effects of HIV/AIDS on the economy of Lesotho
A disaster can have severe socio-economic impacts on a society (Benson et al. 2007:92). A detail
discussion of the effects of HIV/AIDS especially HIV/AIDS related deaths on the economy of
Lesotho is broad and far reaching and it is not the main focus of the research. However a brief
discussion of these effects is included in this sub section.
About 80% of all AIDS deaths are from the active population between the ages of 15-49 years
(Kimaryo et al. 2004:69). This increases the dependency ratio as adults in their prime die leaving
behind old and orphaned children (Slater and Wiggin, 2005:1). These orphaned children
especially girls, may be forced to leave school to give care to their siblings or may be forced into
excessive child labour (Nattrass, 2002:9). AIDS deaths cause a huge loss for the country in terms
62
of human capital and the supply of labour to the various sectors of the economy (UNECA-SA,
2006:6). This makes HIV/AIDS the single most important development challenge, as well as the
leading public health problem since HIV/AIDS has overwhelmed the health sector in Lesotho
(Kimaryo et al. 2004:67; MOHSW, 2008:5). The agriculture and education sectors, for which
studies have been carried out, are seriously affected (Phamotse, 2008:5; ILO/USDOL, 2005).
The demand and supply of education in Lesotho has been seriously affected by HIV/AIDS and
so has the supply of food. There is serious food insecurity in Lesotho and this has increased the
vulnerability of the population to HIV/AIDS (GOL, 2006:33; IAVI, 2005:7). There is evidence
that HIV/AIDS can devastate a whole region (like the southern African region), knock decades
off national development, widen the gap between the rich and the poor and push already
stigmatized group close to the margin of the society (Jackson, 2002:1). The cost of medical bills,
transport to health centres, cost of alternative diet, loss of income and funeral expenses due to
HIV/AIDS related morbidity and mortality, may entail that family savings are liquidated, family
assets sold off, family debts increased and poverty exacerbated (Slater and Wiggin, 2005:2).
Besides, HIV/AIDS increases production cost due to increase in absenteeism and high employee
turnover due to infected workers. The fiscal balance and therefore the development programme
of the country is also affected (CBL, 2004:1). Despite all these, there is still information gap on
the impacts of HIV/AIDS on all sectors of the economy of Lesotho (GoL, 2006:52). However,
with such a high prevalence, morbidity and mortality rates, there is high probability that all
sectors of the Lesotho economy have been negatively affected by HIV/AIDS. It only suffices to
find out through further research, the extent of these impacts.
3.5 SUMMARY
Chapter three is on related literature on the phenomenon of HIV/AIDS. The chapter focuses on
the demographic impact of HIV/AIDS and starts by examining the global situation and then the
literature narrows down to situation in Lesotho. To examine the demographic impact of
HIV/AIDS, data sources are obtained from international, regional and local sources. The data
exist in the form of books, electronic materials from the internet, publications from the United
Nations agencies, individual researches, publications from government departments, personal
experiences to name but a few. The proper review of literature begins with a brief historical
63
background of HIV/AIDS, how it started, where the name came from and how HIV/AIDS
developed until it became a global pandemic and even a disaster in some countries like Lesotho.
The next sub section examined the global demographic impact of HIV/AIDS with focus on its
effect on the demographic processes using different parameters. The global prevalence rate was
used to examine regional differences in the spread of the pandemic. The global AIDS deaths
were then examined by looking at the total reported deaths per region and how the deaths have
affected the life expectancy in the world. Analysis showed that sub Saharan Africa is the most
affected region with southern Africa as the epicentre of HIV/AIDS. The situation in Lesotho was
then examined in detail. The HIV/AIDS prevalence rate in Lesotho was examined by looking at
the spatio-temporal distribution of the infected people. It was realised that the HIV prevalence
rate has stabilised at 23.2% since 2005 but that Lesotho is still the third highest infected country
in the world. Prevalence rates were higher in urban areas than in rural areas and certain social
groups were more at risk such as young women, children, commercial sex workers, miners
etcetera. Next was the examination of the impact of HIV/AIDS on mortality. Here, it was
observed that HIV/AIDS has increased the morbidity and mortality rate in Lesotho. This increase
in mortality has led to a corresponding fall in life expectancy in Lesotho. Migration was then
examined as a factor that could fuel the spread of HIV/AIDS. Rural-to-urban migration indirectly
increases the spread of HIV/AIDS in Lesotho especially with the case of young women who
leave the rural areas to seek for jobs in the apparel industries and were reported to have one of
the highest HIV infection rate in Lesotho. Migrant workers especially mine workers who migrate
to the mines in South Africa were reported to be good vectors for the spread of HIV/AIDS in
Lesotho. A brief overview of the impact of HIV/AIDS on children showed that there were many
orphan and vulnerable children in Lesotho. The plight of these OVC needs further research.
Further research is also needed on the impact of HIV/AIDS on other sectors of the Lesotho
economy beside the health, education and agriculture sectors for which some research has been
made. These three sectors have been negatively affected by HIV/AIDS. All in all, HIV/AIDS has
serious negative demographic and other impacts in Lesotho and the situation is still precarious.
There seems to be lack of important data as well as lack of access to data on HIV/AIDS in
Lesotho. This problem of lack of data is possibly exacerbated by poor coordination of HIV/AIDS
intervention activities in Lesotho.
64
CHAPTER FOUR
THE EMPIRICAL INVESTIGATION AND DATA ANALYSIS
4.1 INTRODUCTION
Chapter four covers the method and procedure used for the empirical investigation in the
research as well as the analysis and presentation of the results. The empirical investigation is
based on the literature study and is aimed at exploring and describing the demographic impact of
HIV/AIDS in Lesotho where HIV/AIDS is found to be a national disaster. Chapter four is
broadly divided into the research design, the research methodology and the analysis/presentation
of the results
4.2 RESEARCH DESIGN
According to Leedy and Ormrod (2001:91), the research design can be seen as the complete
strategy on how to tackle the central research problem and it provides the overall structure of the
procedures that the researcher follows, the data that the researcher collects and how the data is
analysed. Viewed almost in the same way, Mouton (2001:55) defines the research design as the
plan or the blueprint of how the researcher intends to conduct the research. Put this way these
authors seem to mix the research design and the research methodology. The definition of
research design can be ambiguous and confusing (De Vos et al. 2005:132) but in this study, the
research design is used to describe the approach the researcher used to address the research
problem and research questions.
This is an empirical research issue (Mouton, 2001:144) and the researcher used a hybrid of both
quantitative and qualitative approaches, but more so of quantitative approach, to address the
research problem and research questions. Quantitatively, the researcher followed the positivist
approach (De Vos et al. 2005:5-7) and focused on Secondary Data Analysis (SDA) (Mouton,
2001:164-165). SDA was mainly used because the researcher could neither feasibly carry out a
national population census nor a national demographic and health survey to obtain the necessary
data that would cover the research theme.
65
However the researcher used questionnaires to generate primary data to complement the
secondary data mentioned above. The questions in the questionnaire were closed-ended
questions (De Vos et al. 2005:174; Kitchin and Tate, 2000) because closed-ended questions are
easy to code, input and analyse when doing data analysis. Besides, the Director and the Public
Relation and Communication Officers of the Lesotho Disaster Management Authority (DMA)
were interviewed in their offices to enable the researcher get an insight on how HIV/AIDS is
managed (as a disaster) in Lesotho. This mixed approach of using both SDA and primary data
sourcing served as a form of triangulation (Rakotsoane and Rakotsoane, 2006:12).
4.3 RESEARCH METHODOLOGY
The research methodology can be seen as what the researcher does with the research problem in
order to arrive at logical conclusions (Hofstee, 2006:107). A literature study, supplemented by an
empirical investigation was used as the research method.
4.3.1 Methodology for Literature Study
The inter-disciplinary and multi-sectoral nature of disaster risk management guided the literature
study and both national and international sources were consulted. The literature was organized to
flow from the general (Global perspective) to the specific (Lesotho situation). The meaning and
historical background of HIV/AIDS was explored, followed by an overview of the global,
regional and then the national demographic impacts of HIV/AIDS.
The pressure and release (PAR) model was presented as a conceptual framework for the
investigation and this enabled the researcher to trace possible weaknesses in Lesotho that were
exploited by HIV/AIDS such that the epidemic degenerated into a national disaster at the
beginning of this century. However, the Demographic Transition Model was also explored to
show the changes in the trajectory of the population of Lesotho as a result of HIV/AIDS.
Meanwhile elements from the Progression of Safety Model are contemplated for
recommendation to tackle the problem of vulnerability to HIV/AIDS in Lesotho.
66
4.3.2 Methodology for Empirical Investigation
For the purposes of empirical studies, both primary data (using questionnaires and an interview)
and secondary data analysis (using the 1976, 1986, 1996 and 2006 national population censuses
as well as data from surveys and review reports carried out by the Lesotho Ministry of Health
and Social Welfare) were used to explore and describe the impacts of HIV/AIDS on the
population structure of Lesotho
Part of the main theme of this research was to establish the need for a new population pyramid
for Lesotho, and to construct a population pyramid for a country like Lesotho requires
comprehensive data that can only be collected during a population census or a Demographic and
Health Survey. Unfortunately, both were in practice beyond the scope, financial and time limit of
a single researcher. Besides, the research is about a very sensitive issue, which many people may
not be willing to freely talk about due to the stigma attached to HIV/AIDS. Also various
legislation in place and professional ethics regarding the disclosure of AIDS related deaths in
Lesotho made primary sourcing very difficult. For all the reasons mentioned above, the
researcher had to rely more on secondary data analysis while the primary data collected from the
questionnaires and the interview was used to flesh out and compliment the secondary data.
Sampling strategy
Sampling means taking a portion of the population or universe and considering the sample as
representative of that population or universe (De Vos et al. 2005:193). Sampling is often used in
research where the population is very large such that every element of the population cannot be
investigated in the research. The golden rule in sampling is that the sample should be considered
to be representative of the population and if the sample is assumed to be representative enough
then the result from the sample could be generalize to the entire population (De Vos et al.
205:193).
In this study, the researcher used mainly secondary data analysis which had national
representation. Besides, the researcher also administered 116 questionnaires with closed-ended
questions to 29 randomly selected medical officers, 75 nurses and seven medical laboratory
technicians using a simple random sampling technique. The health personnel were used for
67
primary sourcing because they deal with HIV/AIDS situations almost on daily basis and their
opinion should give a good indication of the HIV/AIDS situation in Lesotho. The respondents
were drawn from 20 health institutions spread out in seven out of the ten districts in Lesotho. The
Directors and the Public Relation and Communication Officers of the Lesotho Disaster
Management Authority were also interviewed in their offices and their responses gave the
researcher an insight on how HIV,AIDS is managed as a disaster in Lesotho. Meanwhile a
demographer and statistician (Ntate Moerane Palesana) from the Lesotho Bureau of Statistics
(BOS) was consulted for expert inputs on the statistical and demographic aspects of the research.
Data collection
The researcher obtained the data from four national population censuses (1976, 1986, 1996 and
2006. See Appendix B). These data were cross-analysed with those collected during the
Demographic and Health Surveys (DHS) by the Lesotho Ministry of Health and Social Welfare
(MOHSW) in 2004 and published by the Lesotho Bureau of Statistics (BOS). The DHS is
conducted every five years and has a national representative sample of people between the ages
of 15-49 years so it was quite informative on the impact of HIV/AIDS in Lesotho. The MOHSW
Annual Joint Review Report for 2008/2009 and the ANC HIV and Syphilis Sentinel Surveillance
Synopsis for 2003, 2005 and 2007 were also used. Apart from the above mentioned sources,
other data on HIV/AIDS published by the UNAIDS and other HIV/AIDS monitoring institutions
in Lesotho were also used. All these sources gave the researcher adequate secondary data.
As a form of triangulation, the researcher also used questionnaires and interview to generate
primary data to complement the secondary data available from the above-mentioned official
sources. Adequate data was thus generated for analysis.
Data analysis
The majority of the data analysis was presented using simple descriptive statistical techniques.
Multivariate data analysis was used and facts and figures presented in the form of tables, graphs
and diagrams. The researcher solicited the service of a senior statistician from the Lesotho
Bureau of Statistics (mentioned earlier on) to help in the statistical analysis of the data. The fact
68
and figures, tables and diagrams were then used to clearly support the logical conclusions and
recommendations that were made by the researcher.
Pilot study
The researcher carried out a pilot study in Maputsoe (see figure 1) which is the closest town to
where the researcher resides. A medical doctor and four nurses were used as respondents to the
questionnaire and their views and comments were used to update the content of the administered
questionnaires (see appendix A). A specialist in questionnaire design from the University of the
Free State (UFS) was also consulted while two colleagues in the English Language department
had a look at the questions in the questionnaire for language editing. All these measures helped
the researcher determine if the questions in the questionnaire were well framed and understood.
Some adjustments were made on some of the questions before field administration of the
questionnaires.
Ethical considerations
Researchers have two basic categories of ethical responsibility which include responsibility to
those who participated in the research and responsibility to the scientific discipline to which they
belong (De Vos et al. 2005:56). These two responsibilities guided the conduct of this research.
The researcher is aware of the values, morals, professional code and ethics that guide
researchers. For example, plagiarism is against the code of research and plagiarism was avoided
in the research. All sources of data and information were acknowledged within the text and in the
list of references.
The researcher had at the back of his mind that HIV/AIDS was and still is a sensitive issue. Any
form of emotional harm was avoided. For example respondents were asked to leave out any
question(s) in the questionnaire they were not comfortable with and their participation in the
study was voluntary. There was no form of coercion or any form of deliberate deception from the
researcher. Meanwhile confidentiality and anonymity of the respondents were strictly adhered to.
Objectivity was maintained and value judgment was avoided throughout the study. The
researcher also made it clear that the findings from the research will be made available and in a
language that is understood by all interested parties including the respondents.
69
However, research can by a tricky exercise. For example, the researcher failed to imagine the
involvement of the ethical committee of the MOHSW on any research involving HIV/AIDS in
Lesotho. The researcher could not therefore proceed to neither collect secondary data from the
Lesotho National AIDS Directorate of the MOHSW nor administer the questionnaire to doctors
and nurses without ethical clearance from the MOHSW. Therefore the researcher had to suspend
data collection and went through the process of ethical clearance from the MOHSW and obtained
the ethical clearance certificate (see Appendix A). After the ethical clearance for the study was
obtained, the researcher then followed appropriate procedure to obtain both primary and
secondary data for analysis. Other young researchers (especially in the area of HIV/AIDS)
should learn from this mistake and it should be noted that information and data on HIV/AIDS is
not as free and readily available in Lesotho as many people may think.
Validation of data
Besides using triangulation, a senior researcher at the National University of Lesotho (Dr. Tanga
Pius) was consulted for cross validation of data and facts presented. The senior demographer
from the BOS (Ntate Moerane Palesane) and the researcher together reviewed the data for the
national population censuses that were used.
It was realized that there were some unexplained discrepancies in the 1976 population census
data and so the necessary adjustment (smoothing) was made. However this adjustment did not
affect the overall value of the data.
Objectivity of the researcher and limitations of the research
The primary data source using questionnaires did not cover all the districts in Lesotho. Seven out
of ten districts were covered. Besides, 116 medical personnel were randomly selected using the
simple random sample. There is need to broaden the sample size to include all the ten districts
and also to increase the number of respondents as well as avoid the random sampling bias that
could affect the generalisaton of the results. Besides, HIV/AIDS is a sensitive issue which many
people do not feel comfortable to talk about. Even some prospects were unwilling to complete
the questionnaires. However these limitations were compensated with the use of SDA which had
national representation like the data from the population censuses and the MOHSW.
70
The empirical study (using questionnaires) was conducted during the period of the scare and
pandemonium of the swine fever. During this period, doctors, nurses and medical laboratory
technicians (the targeted respondents) were very busy, so this affected the response rate and
increased the number of repeated visits by the researcher. Besides, the researcher was also scared
(but had to brave the storm) of getting into certain wards to administer the questionnaires for fear
of contracting communicable diseases especially the swine fever. This in a way affected the
recruitment of the respondents.
The researcher also faced much financial difficulty as the research was sponsored entirely by the
researcher. This constraint in a way affected the sample size, the quality and the aesthetic
presentation of the research findings. Time was also a major constrain that affected especially the
sample base of the survey.
Coming from a disaster management perspective could influence the way the researcher
evaluated the management of HIV/AIDS as a disaster in Lesotho. Luckily, this aspect of the
research was not comprehensively investigated because it was not a central theme in the research
problem.
The researcher was almost suffocated by the volume of existing literature on HIV/AIDS but most
of which did not address the research problem. For this reason, large volumes of literature had to
be consulted in order to get the relevant facts for the study. This showed a clear indication that
this research was a good niche in the study of HIV/AIDS in Lesotho.
The conceptual framework that was used in the research (cf. Chapter two) could not cover the
entire research problem and research questions. Other frameworks exist in disaster management
that could also be used. Examples of these frameworks include the Sustainable Livelihoods
framework, Capacity and Vulnerability Analysis, Access model, the Disaster management
framework, and the disaster management continuum, to mention but a few.
However, despites the above mentioned limitations and problems, the general procedure and the
findings from the research were not significantly affected.
71
4.4 DATA ANALYSIS AND PRESENTATION OF RESULTS
The various data sources (both primary and secondary), the analyses and interpretation of the
data are outlined in this sub section. The outline of this sub section consists primarily of three
parts. Viz: a part in which secondary data on population dynamics and the effects of HIV/AIDS
in Lesotho are outlined, a part in which the results from the questionnaires that were
administered by the researcher are outlined and a part where the results from the qualitative
interviews on the management of HIV/AIDS in Lesotho are also outlined. Though the sub
section is broadly divided into three parts as indicated above, the analysis and interpretation of
the primary and secondary data are done together to enable the researcher have a clearer picture
of the impacts of HIV/AIDS on the population structure of Lesotho.
4.4.1 Secondary Data Analysis (SDA)
In this sub section, the researcher used secondary data to examine the demographic dynamics in
Lesotho between 1976 and 2006. The choice of these dates was guided by the fact that the
researcher wanted to include some time before HIV/AIDS was first reported in Lesotho in the
1980s and then go through the HIV/AIDS era up to the latest national population census in 2006.
During this period, the researcher could pick up population changes that could be linked to the
impact of HIV/AIDS. The main data used were those from the four national population censuses
viz, 1976, 1986, 1996 and 2006 (see Appendix B). Besides, data from the Lesotho Demographic
and Health Survey of 2004 as well as data from the UNAIDS, UN Secretariat and data from the
MOHSW were incorporated in the analysis.
Trends in the demographic indicators
Past vital demographic indicators were captured from various secondary sources. Although the
analysis of these indicators was focused on the years that the national population censuses were
held in Lesotho, data from other years were also explored in order to paint a good picture of the
demographic impact of HIV/AIDS in Lesotho.
72
Table 4.1: Summary of the demographic dynamic indicators in Lesotho
Indicators/Year
1976
1986
1996
2006
Total population (De jure)
1,216,815
1,595,096
1,862,275
1,880,661
Crude Birth Rate(per thousand)
42
38
34
31
Crude Death Rate(per thousand
15
12
12
18
Net Migration(per thousand
-20
-73
-36
-36
2.6
1.5
0.1
Intercensal Growth Rate (in 2.27
percentage)
Sex ratio
93.3
95.6
95.6
95.0
Total Fertility Rate(TFR)
5.4
5.3
4.1
3.5
Life Expectancy: Male
49
54
59
49
53
57
60
57
Female
Source: BOS, 1976, 1986, 1996, 2006; DHS 2004; United Nations Secretariat, 2007
From table 4.1 it is clear that the total population of Lesotho was increasing at a decreasing rate
especially after HIV/AIDS was reported in the 1980s. This effect was quickly picked up in the
growth rate and the later has persistently been falling. To buttress this point, the highest net
migration as reported by the UN Secretariat coincided with the advent of HIV/AIDS in the
1980s. Most Basotho migrate to South Africa as mine workers. These returning mine workers
have been reported earlier in this research as one of the main vectors for the spread of
HIV/AIDS. A large number of these migrants and their infected spouses must have subsequently
died, thus halting and later reversing the downward trend in the crude death rate that sharply
jumped from 12 per thousand in 1996 to 18 per thousand in 2006. There was neither war nor any
hazardous event in Lesotho during this period that could result to such a loss in human life at
such a scale, so the only logical explanation is the impact of HIV/AIDS. It should also be noted
that the total population of Lesotho was 2.3 million people in 2003 (GOL, 2005) before falling to
almost 1.9 million in 2006. Possibly the majority of people who were infected with HIV/AIDS in
the 1990s had not started dying when the national demographic and health survey was conducted
in 2004.
73
Table 4.2: Estimated Annual HIV positive births (2002-2010) in Lesotho
2002
Total
2003
HIV+ 2,765 2,690
2004
2005
2006
2007
2008
2009
2010
2,631 2,507 2,134
1,682 1,281
1,056 859
4.35
2.86
1.81
births
Percentage(of
4.49
4.41
4.18
3.59
2.19
1.47
total births
Source: Adapted from MOHSW, 2008:67
Though it may be difficult to relate the dynamics in the crude birth rate (CBR) and the total
fertility rate (TFR) over the years to the impact of HIV/AIDS, it is clear from table 4.2 that
thousands of children were born and are still born HIV positive. However, the good news is that
the total number as well as the percentage of HIV positive births has been falling, possibly due to
effective PMTCT measures that have been put in place in Lesotho.
Table 4.3: Estimated cumulative AIDS deaths (2002-2010) in Lesotho
2002
2003
2004
2005
2006
2007
2008
2009
2010
Total
60,860
78,280
97,452
117,282
134,794
153,194
169,607
185,453
200,545
Male
32,139
40,90
50,397
60,059
68,464
77,161
84,816
92,116
98,996
Female
28,721
37,372
47,055
57,223
66,330
76,032
84,791
93,337
101,550
Source: Adapted from MOHSW, 2008:67
Lesotho lost 185,453 people due to HIV/AIDS within seven years giving an average death toll
of 26,493 people per year. From table 4.3 it can also be observed that at first more males died
from AIDS than women but currently more women are dying than men. A possible logical
explanation for this trend could be that although both male and female may be infected at the
same time, possibly the natural anatomy of women make them live longer with the HIV virus
than their male counter parts. Now with the maturing of the epidemic, the death toll on females is
surpassing that of males.
74
Table 4.4 Deaths due to HIV/AIDS in Lesotho in 2008
Total deaths
Deaths due to AIDS
Percentage
Male
2740
771
28
Female
2447
850
34
Children 12 years and below
1383
185
13
Source: MOHSW, 2009:36-38
Among the top ten main causes of deaths in 2008, HIV/AIDS was number one cause of death
among male, number two main cause of death among women and number four main cause of
death among children 12 years and below (MOHSW, 2009: 36-38). In total about 1806 people
died due to HIV/AIDS in Lesotho in 2008 alone (table 4.4
Figure 4.1: HIV prevalence rate, new HIV infections and AIDS deaths (1990-2007)
Source: UNGASS, 2008:5
The peak of HIV infection in Lesotho was in 1995 while the peak of AIDS deaths was in 2005.
This corresponds to the average lifespan that an HIV infected person is expected to live. Though
AIDS deaths are stabilizing after 2005, they are doing so at a very high number especially given
75
the small size and the downward trend in the total population of Lesotho in recent years. Given
that most of those who die from HIV/AIDS come from the economically active population, the
general economy of Lesotho is negatively affected (see 3.4.6).
Changes in the Population Structure
This section looked at changes in the past four population structures as reflected in the changes
in the population pyramids. Attempt was then made to analyse which of these changes in the
population structured could be attributed to the impact of HIV/AIDS.
The population structure of every country is best graphically represented in the form of a
population pyramid. National data (normally obtained from national population censuses) are
needed to construct such a pyramid. Between 1976 and 2006, Lesotho conducted four national
population censuses and data from these censuses (see Appendix B) were used to construct the
four population pyramids shown in figures 4.2a, 4.2b, 4.2c and 4.2d below
Figure 4.2a: Population pyramid of Lesotho in 1976
76
Figure 4.2b: Population pyramid of Lesotho in 1986
Figure 4.2c: Population pyramid of Lesotho in 1996
77
Figure 4.2d: Population pyramid of Lesotho in 2006
Attention was focused on the last three population pyramids because the first case of HIV/AIDS
was discovered in Lesotho in 1986 (see Chapter three). A careful look at the last three pyramids
therefore showed that the bases of the pyramids were continuously reducing. Though there was a
natural tendency in the fall in fertility rates (see Table 4.1), HIV/AIDS affected fertility in
Lesotho and also HIV/AIDS accelerated infant mortality, thereby causing the noticeable
shrinking in the base of the pyramids. Besides, the number and percentage of the active
population was also reducing as noticed in the indentation of the 1996 and 2006 population
pyramids. By 2006, most adults who were infected by 1995, the year which marked the peak of
HIV/AIDS prevalence rate in Lesotho (see Figure 4.1), started dying in great numbers and
therefore caused the indentation observable especially in the 2006 population pyramid. The tops
of the population pyramids were even getting narrower and narrower as general life expectancy
continued to fall (see Table 4.1) and heavy burdens of HIV/AIDS shifted continuously to the
aged or the grey population. The socio-economic and psycho-social impact of HIV/AIDS must
have also precipitated the death of this elderly population of Lesotho who now had to take care
of themselves as well as their AIDS-orphaned grandchildren.
78
The impact of HIV/AIDS on children
Children could be infected or lose their parents due to HIV/AIDS. The numbers of AIDS orphans
have been increasing tremendously in Lesotho and currently there are about 120,000 AIDS
orphans who add to the number of OVC in Lesotho (NAC, 2009:1). The OVC are a very
vulnerable group of the population and they have special socio-economic and psycho-social
problems which may not have been adequately addressed in Lesotho (see 3.4.5).
4.4.2 Primary Data Analysis
This section outlines the results of the 116 questionnaires that were completed by doctors, nurses
and medical laboratory assistants in 20 health institutions spread in seven districts in Lesotho.
The health institutions included those that are owned by the Government of Lesotho (GOL),
those that belong to the Christian Health Association of Lesotho (CHAL) and private health
clinics. In this section also the qualitative interpretation of the interview that was granted to the
Chief Executive Officer (CEO) and the Public Relation and Education officer of the Lesotho
Disaster Management Authority is analysed.
Background and demographics of the respondents
Questions one to six in the questionnaire covered the demographics of the respondents.
Seven out of ten districts were covered and most questionnaires were administered in Berea,
Leribe and Maseru districts (table 4.5a). These three districts have big towns (TY, Mapusoe,
Hlotse and Maseru) with high concentration of the Lesotho population therefore adding value to
the data collected.
79
Table 4.5a: Questionnaires per District
Cumulative
District
Frequency Percent
Valid Percent Percent
24
20.7
20.7
20.7
Buthe-Buthe
9
7.8
7.8
28.4
Leribe
25
21.6
21.6
50.0
Berea
28
24.1
24.1
74.1
Mafeteng
12
10.3
10.3
84.5
Mohale's Hoek 8
6.9
6.9
91.4
Thaba Tseka
10
8.6
8.6
100.0
Total
116
100.0
100.0
Valid Maseru
Most respondents were female nurses, followed by doctors and only seven medical laboratory
assistants were involved (table 4.5b and 4.5c).
Table 4.5b: Title of the respondents
Title
Cumulative
Frequency Percent
Valid Doctors 29
Valid Percent Percent
25.0
25.0
25.0
Nurses
80
69.0
69.0
94.0
Other
7
6.0
6.0
100.0
Total
116
100.0
100.0
80
Table 4.5c: Gender of respondents
Cumulative
Frequency Percent
Valid Percent Percent
43
37.1
37.1
37.1
Female 73
62.9
62.9
100.0
Total
100.0
100.0
Valid Male
116
The modal age group of the respondents was 25 to 39 years (table 4.5d) while their modal length
of service was in the one to five years group. This indicates rather young and probably
inexperienced health personnel in Lesotho. Possibly the more experienced health workers have
left the country for greener pastures overseas or affected by the HIV/AIDS pandemic.
Table 4.5d: Age of respondents
Cumulative
Frequency Percent
Valid 18 to 24 8
Valid Percent Percent
6.9
6.9
6.9
25 to 39 67
57.8
57.8
64.7
40 to 49 29
25.0
25.0
89.7
50 to 59 10
8.6
8.6
98.3
60 +
2
1.7
1.7
100.0
Total
116
100.0
100.0
81
Table 4.5e:Length of Service of the respondents
Cumulative
Frequency Percent
Valid Percent Percent
Valid Less than 1 Year 10
8.6
8.6
8.6
1 to 5 years
55
47.4
47.4
56.0
6 to 10 years
19
16.4
16.4
72.4
11 to 15 years
15
12.9
12.9
85.3
16 to 20 years
5
4.3
4.3
89.7
21 +
12
10.3
10.3
100.0
Total
116
100.0
100.0
AIDS related mortality data
The following information was generated from AIDS related mortality data during the study:
 Rating of HIV/AIDS as a cause of death
Question 18 in the questionnaire required the respondent to rate HIV/AIDS as a cause of death in
Lesotho and the results are presented below.
About 71 out of 116 of the respondents ranked HIV/AIDS as number one cause of death (figure
4.3). This is in agreement with studies carried out by the MOHSW in 2008 and sited in 4.1
above. Therefore AIDS is still a major killer of people in Lesotho
82
Figure 4.3 HIV/AIDS as a cause of death
 HIV/AIDS and gender
Questions 10 and 11 in the questionnaire were based on gender related effects of HIV/AIDS.
From table 4.6 it is clear that most of the respondents (63.8%) indicated that women are more
affected by HIV/AIDS than men. This view is in line with most of the secondary sources
consulted by the researcher. About 24% of the respondents felt the impact of HIV/AIDS was
almost equally shared between males and females in Lesotho.
Table 4.6:Most Affected Gender
Cumulative
Frequency Percent
Valid Percent Percent
14
12.1
12.1
12.1
Female
74
63.8
63.8
75.9
Fairly
28
24.1
24.1
100.0
116
100.0
100.0
Valid Male
Balanced
Total
83
 AIDS mortality impact by age
Question eight asked the respondents to indicate the age group with the highest mortality while
question nine asked the respondents to indicate the percentage of the total mortality that can be
attributed to HIV/AIDS. The results according to this study were that, most of those who die as a
result of AIDS (83.6%) fall within the active population or the labour force of the country (table
4.8). The fall in the active population due to AIDS deaths will have serious demographic effects
on the total fertility rate, the dependency ratio as well as other socio-economic effects in Lesotho
(see 3.4.6).
Table 4.7: AIDS mortality by age group
Cumulative
Frequency Percent
Valid 0 to 19 years 7
Valid Percent Percent
6.0
6.0
6.0
20 to 49 years 97
83.6
83.6
89.7
50 to 69 years 12
10.3
10.3
100.0
Total
100.0
100.0
116
 Trend in AIDS related deaths
Question nine in the questionnaire required the respondents to rate AIDS related deaths in
Lesotho and question 12 asked them to indicate whether the number of HIV/AIDS related deaths
have been rising, falling or constant for the past five years.
From the results, about 52.5% of the respondents rated AIDS related deaths in Lesotho to be
either high or very high (figure 4.4) while most respondents believe AIDS related deaths are still
on the increase (figure 4.5). This trend which indicated increase in AIDS related deaths is
probably so because as the epidemic is maturing (with a levelling in the prevalence rate at 23.2%
since 2005) most of the people who were infected before 2005 are now dying.
84
Figure 4.4 Rating of AIDS related deaths
Figure 4.5 Trends in HIV/AIDS
Fertility related data analysis
Information was generated from the fertility related data and is presented below:
 Antenatal attendance as source of fertility data
85
Question 13 in the questionnaire asked for the average number of women who attend antenatal
clinic per month. The results showed that on the average less than 100 women attend antenatal
clinic per month especially in the rural areas but the good news was that most antenatal attendees
(about 75% or more) especially pregnant women attending for the first time were tested for
HIV/AIDS (figure 4.6). The later was captured by question 14 which asked respondents to
indicate the percentage of antenatal attendees who are tested for HIV/AIDS. The practice of
testing most antenatal attendees has possibly contributed a lot to the prevention of mother-tochild transmission (PMTCT). The PMTCT facility sites increased in Lesotho from 35 in 2007 to
180 sites by March 2009 (MOHSW, 2009:47). This is a good trend with much hope for the
future generation of Lesotho.
Antenatal HIV testing
Less than 25%
25-50%
50-70%
More than 70%
Figure 4.6 Antenatal HIV testing
 Trend in births and risk of Mother-To-Child Transmission (MTCT) of HIV
Question 16 asked the respondents to indicate the general trend in live-born babies and question
17 asked the respondents to indicate the proportion of these live-born babies who may be at risk
of contracting HIV/AIDS from their infected mothers. From this study, the average number of
babies born per month was increasing (figure 4.7) meanwhile the risk of exposure of these live
86
born babies to HIV from their HIV positive mothers was either low or moderate (figure 4.8).
Again PMTCT measures should be playing a key role.
It was quite interesting to note from returning comments in this research that the number of
babies born between August and October in Lesotho are often more than the total number of
babies that are born in all other nine months put together and that births are highest in the month
of September in Lesotho. This concentrated peak in births is possibly the „Christmas gift‟ from
returning miners who spend most of the year in the mines in South Africa and return to Lesotho
during the Christmas break; during which time the returning miners have enough time to be with
their spouses. More time is thus created to make babies.
Trend in births (%)
Increasing
Falling
Constant
Cannot tel
Figure 4.7 Trend in births (%)
87
Cannot tell
R
a
n
k
i
n
g
Very high
High
Moderate
Ris
Low
Very
Figure 4.8 RISK
OFlow
MTCT
5
10impacts of15HIV/AIDS20in Lesotho25
Summary views of0the respondents
on the
In question 19, the respondents were asked to indicate their views on six parameters that could
Percentage of repondents
be used to describe the general demographic impact of HIV/AIDS in Lesotho. Each respondent
could choose more than one parameter. The results are presented in table 4.8
Table 4.8: General view of the respondents on the impacts of HIV/AIDS in Lesotho
Number Parameter
Score
Percentage
1
Sex ratio has changed in Lesotho
12
3.4
2
Total population has reduced
48
13.5
3
HIV/AIDS is the main cause of population reduction
58
16.3
4
HIV/AIDS still a serious problem in Lesotho
99
27.9
5
HIV/AIDS affects more poor people than rich people
50
14.1
6
The number of AIDS orphans still on the increase
88
24.8
355
100
Total
HIV/AIDS is still a major problem in Lesotho. It is the main cause of the population reduction
from 2.3 million in 2003 (MOHSW, 2005:1) to 1.8 million people in 2006 (BOS, 2007:2).
88
30
HIV/AIDS has produced and is still producing many AIDS orphans in Lesotho thus exacerbating
the socio-economic and psycho-social needs of OVC in Lesotho.
Analysis of the interview results
Qualitative method was used to analyse the interview results. The researcher had interview with
the Chief Executive Officer (CEO) and the Public Relation and Education officer of the Lesotho
Disaster Management Authority (DMA) on 02 September 2009. The main aim of the interview
was to find out the role that DMA played or is playing in the management of HIV/AIDS as a
disaster in Lesotho. It should be noted however that the management of HIV/AIDS was not a
major theme in this research and could therefore form part of a further research. However from
the interview and the personal experience of the researcher, the following points could be noted:
 HIV/AIDS is a unique disaster in Lesotho and is managed differently from other
disasters.
 DMA may not be playing the central coordinating role as it does in other natural and
human induced disasters (Disaster Management Act Number 26 of 1997, section
13a) but DMA works with partner organisations especially in the area of advocacy.
All role players share a common goal of up scaling the pandemic in the country.
 DMA focuses mainly on Disaster Risk Reduction (DRR). The DRR is the systematic
development and application of policies, strategies and practices to minimize
vulnerability and disaster risk in a society, to avoid (prevention) or to limit
(mitigation and preparedness) the adverse impact of hazards within the broad context
of sustainable development (UNISDR, 202:338). DRR is a proactive approach in
disaster risk management and it is a new approach that has been adopted by the
international community since the Hyogo World Conference on Disaster Reduction
in 2005.
 DMA is also a strong adherent of the Prime Minister‟s doctrine of “ABC or D”
meaning Abstain from sex, Be faithful to your sex partner(s), use Condoms during
sexual intercourse or you Die of AIDS. The Prime Minister of Lesotho is also the
89
champion of “Know Your Status” campaign in Lesotho; a campaign that was
launched in 2006 and was used since then as one of the best practice response tool to
reduce the spread of HIVAIDS in Lesotho (Whiteside, 208:3). Since HIV/AIDS has
no cure which could be used as a better response tool for the management of the
pandemic, knowing your HIV status could be a good starting point to response to the
pandemic.
 Though no national workplace policy exist in Lesotho for people living with
HIV/AIDS (PLWHA), the DMA vehemently condemns any form of discrimination
against PLWHA and has put in place support systems for its workers implicated in
HIVAIDS.
 The new paradigm of DRR as spelt out in the Hyogo Frame Work for Action (to
which Lesotho is signatory) is still not well understood by many people. The paucity
of evidence on the benefits of DRR is a stumbling block in attracting the interest and
commitment of policy-makers (Benson et al. 2007:92). This lack of evidence
mentioned above partly explains the reasons for the lack of support and cooperation
from many decision makers especially the politicians on DRR programmes. This is a
challenge facing stakeholders in disaster management in many countries in Africa,
including Lesotho.
Key findings from the empirical study
From the empirical study that was done involving secondary data analysis, questionnaires and
interview, the following can be established:
 HIV/AIDS has affected all the components of the population structure of Lesotho
(CDR, CBR, TFR, age and sex composition) but the highest impact was the rapid
increase in morbidity and mortality rates;
 Demographers and population geographers would need to redraw the population
pyramid of Lesotho and other developing countries that are heavily affected by
HIV/AIDS so that the new population pyramids will reflect the impact of HIV/AIDS;
90
 The number of AIDS orphans and therefore the number of OVC continue to rise in
Lesotho. This very vulnerable group of the population may have unmet psycho-social
and other needs because the death of their parents means they lost their primary care
givers and socio-economic support base;
 HIV/AIDS disaster had a different management set up from other natural and human
induced disasters in Lesotho. The central coordination role is played by the Lesotho
AIDS Commission (NAC) and not the Lesotho Disaster Management Authority
(DMA) as could have been imagined following the Lesotho disaster management act
number 26 of 1997. The rationale and the efficacy of this special arrangement was not
part of this research;
 There is need to improve on the strategies to combat the effects of HIV/AIDS. For
example there is urgent need to research on and implement strategies that could bring
about remarkable positive changes in behaviour towards HIV/AIDS and towards
those living with HIV/AIDS. Such strategies should be backed by effective national
policies.
4.5 SUMMARY
Chapter four examined the empirical investigation, data analysis and presentation of results. The
chapter began with the methodology for the empirical investigation by first looking at the
research design, then the research procedure and later the analysis, interpretation and
presentation of empirical data. The researcher used a mixture of quantitative and qualitative
approaches to address the research problem and the research questions. Both secondary data
analysis (SDA) and primary data collection were also explored. The SDA focused on the
examination of data from four national population censuses (1976, 1986, 1996 and 2006). The
SDA was used because the researcher could not feasibly undertake a national population census
or a national demographic and health survey to address the research problem. Besides the
population census data, the researcher also examined data from UNAIDS, WHO, Lesotho
91
MOHSW and the National Aids Commission in order to examine the impact of HIV/AIDS on
the population structure of Lesotho. Primary data was collected in two ways. Firstly, 116
questionnaires were completed by doctors, nurses and medical laboratory technicians in seven
out of ten districts in Lesotho. The questionnaires were analysed using simple descriptive
statistical techniques. The results from these questionnaires were used to compliment the SDA
and served as a form of triangulation. Secondly, an interview was conducted with the CEO and
the Public Relation and Education Officer at the Lesotho Disaster Management Authority
(DMA). This interview threw more light on the management of HIV/AIDS as a disaster in
Lesotho. The major findings from the empirical investigation were that HIV/AIDS has changed
the population structure of Lesotho, the number of AIDS orphans and therefore the number of
OVC are still on the rise in Lesotho, many research opportunities exist and lastly that DMA was
not playing the central role in the management of HIV/AIDS disaster in Lesotho. Results from
the empirical investigation and findings from the literature review (see Chapter two and Chapter
three) were used to make the conclusions and the recommendations that constitute chapter five of
this research
92
CHAPTER FIVE
CONCLUSIONS AND RECOMMENDATIONS
5.1 INTRODUCTION
For purposes of this study, a literature study was done initially in which the impact of HIV/AIDS
on the population structure of Lesotho was investigated. However before funnelling the literature
study down to the specific situation in Lesotho, a general overview of the HIV/AIDS situation in
Africa and the rest of the world were explored (cf. 3.3). The literature study was carried out from
a disaster management background and the progression of vulnerability (PAR) model was used
as the conceptual framework for the study (cf. 2.1). However, the theory of demographic
transition was also explored to complement the PAR model in the study. The PAR model was
used in this study because it explains the progression of vulnerability to the impact of HIV/AIDS
in Lesotho by looking at the root causes, the dynamic pressures and the unsafe conditions that
led HIV/AIDS hazard to become a disaster in Lesotho. Meanwhile to examine how the impact of
HIV/AIDS has changed or is changing the demographic trajectory of Lesotho, the demographic
transition theory was also explored in the literature study (cf. 2.3). To supplement the literature
study, an empirical investigation and Secondary Data Analysis were undertaken (cf. Chapter
four). For the purposes of empirical investigation, closed-ended questionnaires were used and an
interview was conducted (cf. 4.3.2). Besides, SDA was also explored using the 1976, 1986, 1996
and 2006 national population censuses data as well as other data from reliable HIV/AIDS
monitoring institutions in Lesotho (cf. 4.3.1). This mixture of data sources served as
triangulation in the study (cf. 4.1). From the literature study, the empirical investigation and
SDA, an attempt was then made to outline and explain the impact of HIV/AIDS disaster on the
population structure of Lesotho. The conclusions and recommendations that flow from the
literature study, empirical investigation and SDA are presented in this chapter.
93
5.2 RESEARCH PROBLEM, HYPOTHESIS AND AIM OF THE STUDY
The research problem was to explore and explain the impact of HIV/AIDS disaster on the
population structure of Lesotho (cf. Chapter one). Some tentative untested statements were also
formulated as part of the research hypotheses (cf. 1.2.2) and included:
That HIV/AIDS has negatively affected all the main components of the population
structure of Lesotho (death rate, birth rate and migration).
That HIV/AIDS disaster may not be managed like other disasters in Lesotho.
That the number of orphans and vulnerable children (OVC) will continue to increase in
Lesotho as a result of the impact of HIV/AIDS
The aim of the research was to outline the demographic changes in Lesotho that could be
attributed to the impact of HIV/AIDS and therefore highlight the need to redraw the population
pyramid of Lesotho that will accommodate such impacts (cf. 1.3.1). The research also aimed at
highlighting the importance of managing HIV/AIDS like other natural and human-induced
disasters by following certain basic disaster management principles and practices. On the basis of
the above research problem, the research hypotheses and the aim of the study, the following
conclusions were formulated.
5.3 CONCLUSIONS
A number of conclusions are made to establish whether the aims of the study have been achieved
and from these conclusions, a couple of recommendations were made (see 5.4).
5.3.1 The PAR model as a conceptual framework.
The PAR model clearly showed the progression of vulnerability in Lesotho to the impacts of
HIV/AIDS that eventually culminated to a biological disaster (cf. Chapter two).
94
Under the PAR model, the economic, social, cultural and political factors that increase the
vulnerability of the Basotho to the impact of HIV/AIDS were examined under three broad
headings which included:
 The root causes
 The dynamic pressures
 The unsafe conditions (cf. figure 2.3)
From this conceptual framework, it was observed that the root causes such as poverty,
transformed dynamic pressures such as rapid population growth to produce unsafe conditions
such as risky behaviours in the face of high intensity (23.2% prevalence rate), long duration
(from 1986 to date), large coverage (the whole Lesotho) and high exposure (almost everybody)
of the HIV hazard. The PAR model and its application showed the progression of vulnerability to
the impact of HIV/AIDS in Lesotho.
In the study, the PAR model alone could not explore and describe the phenomenon of HIV/AIDS
and therefore the Demographic Transition Model (DTM) had to be included (cf. figure 2.2). The
DTM showed the impact of HIV/AIDS on the demographic trajectory of Lesotho by examining
the characteristics of the population structure of Lesotho before the advent of HIV/AIDS and the
current characteristics. Based on the DTM it was clear that HIV/AIDS has halted and even
reverse the population trajectory of Lesotho. The utilisation of both the PAR model and the DTM
in this research made the researcher to realise that the multi-disciplinary and cross-cutting nature
of disaster management as a discipline makes it difficult to use one framework to address
disaster problems and this may often necessitate the use of a combination of research approaches
and theoretical frameworks or models (cf. 4.1) when carrying out research in disaster
management.
5.3.2 The research problem
The research problem (cf. Chapter one) was examined with the help of the research questions (cf.
1.2.2) and the research hypotheses (cf.1.2.3). These research questions and hypotheses were
explored in the literature review (cf. Chapter three) and the empirical study (cf. Chapter four).
From the pursuing analysis, it was concluded that HIV/AIDS has actually affected and changed
the three main parameters (the death rate, the birth rate and migration) that influence not only the
95
total population but also the population structure of Lesotho. For example HIV/AIDS was the
major contributor to the recent sharp increase in deaths as reflected in the increasing crude death
rate (cf. 4.1). Though the natural trend in fertility was falling, HIV/AIDS has accelerated the fall
in total fertility rate and the crude birth rate (cf. Chapter four). Although it was difficult to
ascribe the changes in the migration trend over the study period to the impact of HIV/AIDS,
there was clear evidence that migrant workers (especially returning miners from South Africa)
were good vectors in the transmission of HIV/AIDS (cf.3.4.4). There was also evidence from
both empirical investigation and literature study that the age composition, the sex ratio and the
dependency ratio has changed in Lesotho because HIV/AIDS affects mostly the active age group
meanwhile women and children are at higher risk of infection (cf. Chapter three and Chapter
four). Though the changes cannot be totally attributed to HIV/AIDS, the later has non-the-less
contributed a great deal to these changes.
HIV/AIDS has led to the increase number of AIDS orphans and this has fuelled up the number of
OVC in Lesotho (cf. figure 3.6). The hope of not losing all the AIDS orphans in the near future
lies in effective prevention of mother-to-child transmission (PMTCT) measures (cf. figure 4.7;
4.9)
There is further evidence from the empirical study and the literature review that HIV/AIDS has
caused the base of the population pyramid of Lesotho to be shrinking and there is also clear
indication of an indentation in the active population group (cf. figure 4.2a, 4.2b, 4.2c, 4.2d).
These changes necessitate the redrawing of the population pyramids of countries that are highly
affected by HIV/AIDS in order to take into account the impact of HIV/AIDS on the population
structure. Most publications on the population structure of developing countries that were made
based on population projections in the 1980s and early 1990s need to be updated to
accommodate the impact of HIV/AIDS for countries like Lesotho. In the demographic study of
the population structure of developing countries, a special trend has thus emerged for countries
like Lesotho which are heavily affected by HIV/AIDS.
The special trend mentioned above needs to be monitored continuously and corrections made
accordingly in further researches so that the impact of HIVAIDS is well documented. The
importance of studying the population structure of a country cannot be over emphasised. For
96
example the population structure of any country is used for national planning and allocation of
resources. Besides, the population structure also has socio-economic implications such as the
dependency ratio, sex ratio and social relationships as well as the production capacity of the
county. Since HIV/AIDS leads to a sharp increase in the death rate of the active population, the
number of young and old people that the few remaining active population takes care of will rise
and this will increase the dependency ratio. Coupled with a fall in the production capacity of the
country (as more of the productive population die of AIDS), the result will be a general fall in
the standard of living of the people. By killing more women than men, AIDS could offset the sex
ratio in Lesotho in the near future and this could complicate social relationships; more men may
have to choose from few women to marry and this may push up the amount of bride price
(Lobola) or the number of gays in Lesotho may increase.
The Lesotho Disaster Management Authority (DMA) does not actually play the central
coordination role in the management of HIV/AIDS as a disaster in Lesotho (cf. 4.3.2). This
central coordinating function is performed by the Lesotho National AIDS Commission (NAC).
By declaring HIV/AIDS a disaster in 2000, logic will go that the DMA or an organ within DMA
will play the coordinating role according to the disaster management act number 26 of 1997
which has not been amended. The reason for this special arrangement and the efficacy of the set
up was not part of the main focus of this research.
Like the disaster management continuum that consist of the pre-disaster, disaster and post
disaster periods (Kesten, 2008), three main time periods could as well be linked to the study of
HIV/AIDS in Lesotho:
 1976-1996 can be called the pre-disaster period which was characterised by slow
infection and spread of the disease
 1996-2006 can be considered as the disaster period and was characterised by high
morbidity and mortality
97
 2006 to date can be termed the post disaster period and is characterised by stability in the
HIV prevalence rate, improvements in MTCT and the increasing use of life-prolonging
ARV drugs
It should be noted however that some of the elements in the three time series observed by the
researcher and mentioned above do overlap and this possibly makes HIV/AIDS a special disaster
in Lesotho because there are still new cases and more people are still dying at the moment.
The empirical study also showed that the HIV/AIDS prevalence rate is still increasing in Lesotho
(cf. figure 4.6). This is contrary to what is stated in most literature consulted (cf. 3.3.1). It will be
premature however to make any definite conclusion on the current HIV/AIDS prevalence rate in
Lesotho because the sample in the empirical study was not large enough and all the districts were
not covered due to financial and time constraints. The good news however is, that the ongoing
demographic and health survey (2009) will shade more light on the current HIV prevalence rate
in Lesotho.
Finally, the research questions and the research hypothesis were sufficiently covered from the
empirical study that was supplemented by the literature review. The research problem was
therefore addressed.
5.4 RECOMMENDATIONS
The recommendations made in this study are consistent with the current HIV/AIDS situation in
Lesotho, the existing resources and infrastructure in the country, the international shift in
paradigm from disaster response to disaster risk reduction (DRR) and the commitment of the
government and people of Lesotho to fight against the HIV/AIDS pandemic.
5.4.1 Practice
The practice in disaster management is to prevent or mitigate the impact of the disaster without
neglecting the response, recovery and rehabilitation of the affected community (cf. 1.8.4). In the
case of HIV/AIDS in Lesotho, all these five facets of the disaster management continuum should
be engaged. HIV/AIDS is considered a disaster in Lesotho because it overwhelmed the existing
98
resources of the country that could be used to fight the negative impacts of HIV/AIDS. Like any
other disaster; HIV/AIDS posed several risks and any disaster risk has three components viz
vulnerability, the hazard and the coping capacity/manageability (cf.2.2.1) The severity of the
impact of any disaster (in this study HIV/AIDS) depends on the degree of vulnerability of the
affected community, the coping capacity/ manageability capacity of that community as well as
the nature of the hazard itself (as measured by the intensity, duration and magnitude of the
hazard). The golden thread therefore is to tackle the disaster risks of HIV/AIDS in Lesotho in a
holistic way. For example to put in place measures that will reduce the vulnerability of Basotho
to the impact of HIV/AIDS such as poverty eradication, increase the coping capacity of the
people by building strong social net works and support systems in the country, put in place
effective manageability measures like improvement on medical facilities and easy access to good
medical services and adopt policies and practices that will reduce the intensity, duration and
magnitude of HIV/AIDS. The latter could include measures such as compulsory instead of
voluntary testing for HIV and the integration of indigenous knowledge with other management
tools such as the “ABC” and “Know your status” campaigns.
5.4.2 Theory
The Progression of Safety Model (see Appendix D) as a theoretical framework is recommended
in this study for purposes of addressing the vulnerability of the Basotho to the impact of
HIV/AIDS (Wisner et al. 2004:291,344) because it gives guides on how to address the root
causes and reduce dynamic pressures of vulnerability so that safe conditions are created that will
prevent or reduce the impact of a hazard like HIV/AIDS. The progression of safety theory is
actually the antithesis of the progression of vulnerability theory (PAR model) which was used in
this study as a conceptual framework. The application of the progression of safety theory to
tackle vulnerability to the impact of HIV/AIDS in Lesotho will imply the following:
 Address the root causes of vulnerability of the Basotho to the impact of HIVAIDS. For
example address the issue of poverty in the country. Tackle ideologies and cultural
practices (cf.2.1.1) that perpetuate the vulnerability of the people of Lesotho to the impact
of the HIV/AIDS hazard
99
 Address the dynamic pressures that translate the root causes into unsafe conditions. For
example the Basotho should control the population growth so that there will be a fair
balance between the resources available and the number of people that depend on these
resources. One way of controlling rapid population growth is to reduce the occurrences of
unwanted and teenage pregnancies through effective family planning measures, good
parental upbringing and sound moral and Christian education. Redress the problem of
rural-urban migration by putting in place rural development programmes that will
stabilise the rural population since HIV prevalence rates are lower in rural areas (cf.
figure 3.4)
 Create safe conditions for the people. For example tackle the problem of child and
women abuse. Put in place tough measures and policies to combat any form of
discrimination and stigmatisation against PLWHA. Make health facilities more accessible
to the people and increase the coverage of ARV drugs to PLWHA.
 Fast-track the development and implementation of the national work-place policy with
regards to HIV/AIDS.
All the above mentioned measures could be exploited to address the problem of HIV/AIDS in
Lesotho. The popular “ABC” campaign slogan that calls on Basotho to abstain from sex, to be
faithful to their partners or to use condoms is too narrow as it focuses only on sex and neglects
other modes of HIV transmission which are equally important. Besides, the “ABC” slogan also
seems to have become a cliché and is therefore falling on deaf ears as there is still no positive
behavioural change in Lesotho with regards to HIV/AIDS (Moeti, 2007:14; UNGASS, 2008:42).
It is high time therefore that the government and other stake holders in Lesotho started exploiting
other measures to upscale the impact of HIV/AIDS in Lesotho; for example make the study of
HIV/AIDS a compulsory and examinable subject in primary, secondary and high schools in
Lesotho as part of education and awareness campaign. More research is needed particularly from
social scientists on ways to effect positive behavioural changes especially among young adults
who are the most affected by HIV/AIDS in Lesotho.
100
5.4.3 Training, education and research
The government should (through the DMA) initiate nation wide education and training of the
Basotho on disaster risk reduction that will include information on the risk of infection and
spread of HIV/AIDS as a new approach in national planning for sustainable development. The
government of Lesotho and partner organisations in Lesotho should intensify the training of
educators, social workers, community based organisations and cultural organisations on the
prevention and management of HIV/AIDS as well as other potential epidemics in the country.
Such massive education will help to change certain aspects of the Basotho culture (like the
culture of denial and silence) and false claims and ideologies (cf.2.1.1). More resources should
be tailored to the PMTCT programmes (cf. figure 4.9) as these programmes hold a bright future
for children who will be HIV/AIDS free. The future of Lesotho lies on the quality of children
that are produced at the present.
Further and continuous research is recommended on the impact of HIV/AIDS on the population
structure of Lesotho because changes in the population structure have far reaching socioeconomic consequences. More and continuous information is needed on the difference between
the natural demographic changes and those that have been induced by HIV/AIDS in order to
evaluate and determine the extent of the impact of HIV/AIDS on the population. Such
information will assist the government on planning and allocation of resources in the country.
More research is also needed on indigenous knowledge and community participatory action
research not only on HIV/AIDS but on other hazards in Lesotho such as hail stones which
destroy crops, lightning and thunder storms which cause a lot of physical damages as well as soil
erosion and general land degradation which are all potential disasters in Lesotho.
More
improvement should be made on HIV/AIDS data capturing and management that will include
data captured by all health facilities including private clinics in the country. This
recommendation is made because, from some of the returning comments in the empirical study,
it seemed that data captured on HIV/AIDS by private clinics was not given the same attention by
HIV/AIDS monitoring institutions in Lesotho as the data from GOL and CHAL medical
facilities.
101
Further research is also needed especially from the social sciences on how to tackle the social
dimensions of the impact of HIV/AIDS. A good example in this domain will be to have more
research on how to effect positive behavioural changes with regards to HIV/AIDS in Lesotho.
It is also recommended that further research be conducted on the impact of HIV/AIDS on the
population structure of Lesotho with a broader sample base than the current study did. More
medical personnel need to be involved and the research should cover all the ten districts in the
country
5.4.4 Policies
It is recommended that a national disaster management policy be formulated that will take care
of all disasters, whether natural disasters or human induced disasters. Such a policy should be in
consistence with the national constitution and other government acts such as the Lesotho
Disaster Management Act Number 26 of 1997. For example, under such a policy, the Lesotho
National Aids Commission could have been created as a special arm of the Lesotho Disaster
Management Authority. This could have given the relevant minister (most likely the Prime
Minister) the constitutional backing to implement compulsory (rather than the current voluntary)
HIV testing as a measure taken under a disaster situation (Lesotho Disaster Management Act
Number 26 of 1997, Section 4: m). The idea of Human Rights violation when people are forced
to test for HIV may not apply if it is done during a disaster situation. For example it is the
constitutional right for citizens of Lesotho to have and own property as well as to have the
freedom of movement as part of their fundamental Human Right and freedom (GOL, 1993:1) but
during disaster situations private property could be destroyed say for easy evacuation of victims
of a disaster and people may be forced to move and live together in resettlement camps. These
exceptional actions are taken to save lives and are not considered as violation of Human Rights,
so the same should apply to HIV/AIDS and compulsory testing for everybody in Lesotho.
The ABC campaign needs to be broadened because it focuses on sex as if sex is the only route of
HIV transmission. Other campaigns such as safe blood transfusion, safe circumcision practices at
the initiation schools and drug-free society campaign should be incorporated into the ABC
campaign for a holistic approach.
102
5.5 CONCLUDING REMARKS
HIV/AIDS is a serious problem in Lesotho and many other countries in Africa. A core lesson
from this study is that when a country or community faces serious social, economic, political and
even physical vulnerability which are coupled with a general lack of coping and manageability
capacity, then such a society is highly exposed to the impacts of a hazard. Such impact may
overwhelm the resources of that society or community and thus produce a disaster. The above
statement explains why HIV/AIDS became a disaster in Lesotho. Many other countries
especially in Africa which are heavily affected by HIV/AIDS should follow the example of
Lesotho and clearly declare HIV/AIDS a disaster.
From this study, it is also clear that HIV/AIDS has affected all the components of the population
structure of Lesotho but in varying degrees. The changes induced by HIV/AIDS have
complicated the natural demographic trend of Lesotho that has and will continue to have far
reaching socio-economic consequences on the society. The current situation poses a challenge to
decision-makers and managers (including disaster managers) on how to contain and reverse the
negative effects of HIV/AIDS on the population. There is also need to redraw the population
pyramid of Lesotho that may taper from the popular triangular-shaped pyramid which is often
used to describe developing countries. One major legacy of HIV/AIDS in Lesotho is the high
number of vulnerable AIDS orphans with special economic and psycho-social needs that have to
be addressed. For example the future of these AIDS orphans might be compromised because
many may not be able to acquire quality education because their parents had died of HIV/AIDS.
The parents of these AIDS orphans are suppose to be the primary care givers and support
systems for these orphans and when these orphans are raised in institutions like orphanages, they
will miss the warm, comfort and guidance from their parents. This parental care is very vital for
the physical and psychological development of the child. Many of these AIDS orphans also drop
out of school in order to take care of their siblings. In fact, the challenges facing AIDS orphans
in Lesotho and measures to address these challenges should be investigated in another research.
It is true that the world and especially developing countries like Lesotho were facing serious
challenges because of rapid population increase before the coming of HIV/AIDS, for example
rapid depletion of natural resources and unemployment. However HIV/AIDS is reducing the
103
wrong segment of the population (mostly the active population) and it is doing so for the wrong
reasons (a debilitating epidemic) and all these impacts of HIV/AIDS only worsen the poverty
situation in Lesotho.
The devastating consequences of HIV/AIDS on the population structure of Lesotho demands
continuous monitoring, improvements on strategies to combat the effects of the pandemic and
the reallocation of national resources by the government of Lesotho and partner organisations to
areas that will minimise these impacts such as the PMTCT.
104
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APPENDIX A: ETHICAL CLARANCE CERTIFICATE
113
APPENDIX B: THE POPULATION OF LESOTHO IN 1976, 1986, 1996 AND 2006 BY AGE
AND SEX
Lesotho population in 1976 by age
and sex
Age
Male
Female
All ages
569,140
569,140
0-4
83,991
83,991
5-9
76,943
76,943
10-14
75,768
75,768
15-19
58,147
58,147
20-24
30,542
30,542
25-29
40,527
40,527
30-34
32,304
32,304
35-39
29,955
29,955
40-44
29,955
29,955
45-49
22,907
22,907
50-54
18,795
18,795
55-59
19,970
19,970
60-64
12,334
12,334
65-69
8,810
8,810
70-74
5,873
5,873
75+
22,319
22,319
Lesotho population in 1986 by age
and sex
Age
Male
Female
All ages
778,566
816,530
0-4
113,671
111,865
5-9
112,892
111,865
10-14
103,549
102,883
114
15-19
80,192
84,919
20-24
66,957
76,754
25-29
55,278
60,423
30-34
46,714
48,992
35-39
39,707
38,377
40-44
32,700
32,661
45-49
29,586
27,762
50-54
28,807
31,028
55-59
19,464
19,597
60-64
15,571
17,147
65-69
14,793
17,964
70-74
7,786
11,431
75+
10,900
22,863
Lesotho population in1996 by age and sex
Age
Male
Female
All ages
913,277
967,010
0-4
106,535
104,883
5-9
123,078
120,526
10-14
132,201
129,405
15-19
114,904
120,474
20-24
86,627
98,147
25-29
64,374
69,552
30-34
56,490
62,064
35-39
47,498
51,649
40-44
40,741
43,028
45-49
35,279
34,094
50-54
27,533
29,125
55-59
22,549
23,296
60-64
21,639
27,269
65-69
12,298
15,801
70-74
8,850
13,220
75+
12,681
24,477
115
Lesotho population in 2006 by age and sex
Age
Male
Female
All ages
904,392
958,468
0-4
101,397
100,598
5-9
106,695
105,252
10-14
110,778
110,160
15-19
114,800
114,589
20-24
101,385
105,677
25-29
82,202
82,665
30-34
60,107
59,423
35-39
45,645
47,845
40-44
39,596
43,703
45-49
34,102
38,519
50-54
28,723
34,361
55-59
23,225
26,923
60-64
16,724
20,975
65-69
13,369
18,659
70-74
13,380
22,229
75-79
6,327
11,814
80-84
3,251
7,247
85+
2,686
7,829
Source: BOS, 1976, 1986, 1996 and 2006
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APPENDIX C: QUETIONNAIRE FOR EMPIRICAL STUDY
QUESTIONNAIRE TO BE COMPLETED BY DISTRICT MEDICAL
OFFICERS, MEDICAL OFFICERS AND NURSES IN LESOTHO
INTRODUCTION
My name is Belle Johanes Amate. I am a final year student doing Master‟s degree in disaster
management with the Disaster Management Training and Education Centre for Africa
(DiMTEC) at the University of the Free State in Bloemfontein. I am carrying out research on
THE IMPACT OF HIV/AIDS ON THE POPULATION STRUCTURE OF LESOTHO. This
research is purely for academic purpose but the research findings could also help in the
understanding and management of HIV/AIDS in Lesotho. Any information you give me will be
treated as confidential. The questionnaire may take you about twenty minutes to complete. Mark
an X in the box that corresponds to the appropriate response.
Example: Which profession deals with HIV/AIDS situations almost on daily basis?
Professions
Accounting
1
Defense
2
Law
3
Medical
4X
Teaching
5
1.
Name
of
your
institution………………………………………………………………
……………………………………………………………………………………………..
117
2. District where the institution is located
District
Maseru
1
Butha-Buthe
2
Leribe
3
Berea
4
Mafeteng
5
Mohale‟s Hoek
6
Mokhotlong
7
Thaba-Tseka
8
Qacha‟s Nek
9
Quthing
10
3. Title of respondent
Title
District Medical Officer
1
Medical Officer
2
Nurse
3
Other (please specify)
4
4. Gender of the respondent
Gender
Male
1
Female
2
118
5. Indicate your age group
Age
Less than 18 years
1
18-24 years
2
25-39 years
3
40-49 years
4
50-59 years
5
60+ years
6
6. How long have you served in this capacity?
Service
Less than a year
1
1-5 years
2
6-10 years
3
11-15 years
4
16-20 years
5
21+ years
6
7. How would you rate the average number of people who die in this hospital per month?
1
2
3
4
5
Very Low
Low
Moderate
High
Very High
(1-3)
(4-6)
(7-9)
(10-14)
(15+)
119
8. What age group records the highest mortality rate in this hospital?
0-19 years
1
20-49 years
2
50-69 years
3
70+ years
4
9. About what percentage of the deaths mentioned in 7 and 8 above can be attributed to
HIV/AIDS?
1
2
3
4
5
6
Very Low
Low
Moderate
High
Very High
Cannot tell
(0-4)
(5-9)
(10-14)
(15-20)
(20+)
10. Based on your response to 9 above, which gender (sex), is most affected?
Male
1
Female
2
Fairly Balanced
3
11. Approximately, what ratio (in percentage) of male to female die of HIV/AIDS related
causes in this hospital?
Male
1
………%
Female
2
………%
120
12. Based on the past records for the last five years, how would you consider the number of
deaths due to HIV/AIDS related causes?
Rising
1
Falling
2
Constant
3
Do not know
4
13. On the average, about how many women attend antenatal clinic at this hospital per
month?
100 and less
1
101-200
2
201-300
3
301-400
4
401-500
5
501+
6
14. About what proportion of these pregnant women who attend antenatal clinic are tested
for HIV?
Less than 25%
1
25-50%
2
50-75%
3
More than 75%
4
121
15. On the average, about how many live-born babies do you have per month in this
hospital?
Live born babies
100 and less
1
101-200
2
201-300
3
301-400
4
401-500
5
501+
6
16. What is the general trend in the number of live born babies in this hospital for the past
five years?
Trend
Increasing
1
Falling
2
Constant
3
Do not know
4
17. About what proportion of every 100 live-born babies are HIV positive in this hospital?
1
2
3
4
5
6
Very Low
Low
Moderate
High
Very High
Cannot tell
(0-3)
(4-6)
(7-9)
(10-14)
(15+)
122
18. How would you rank HIV/AIDS as a cause of death in this hospital?
Cause of death
Number one
1
Number two
2
Number three
3
Number four
4
Not among the top four
5
19. Indicate by placing a cross (X) on the items that best describe your view point about
HIV/AIDS.
The sex ratio (percentage of male to 1
female) has changed in Lesotho
The total population of Lesotho has 2
reduced since the last five years
HIV/AIDS is the main cause of the 3
decrease in population of Lesotho
HIV/AIDS is serious problem in Lesotho
4
HIV/AIDS affects more poor people than 5
rich people
The number of AIDS orphans have 6
increased since the last five years
Comments:
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………
THANK YOU VERY MUCH FOR YOUR CONTRIBUTION AND TIME!!!
123
APPENDIX D: THE PROGRESSION OF SAFETY MODEL
Source: Wisner et al. 2004:344
124