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[This article was published in 2009 and updated in May 2012. Read the update here.]

Lesotho is facing an HIV crisis equal in extent to neighboring South Africa’s but lacks the resources of its larger neighbor. One bright spot is the surging apparel industry, which exports most of its production to the United States thanks partly to Lesotho’s dutyfree status. The nation has built a reputation for ethical labor practices, and this greatly enhances its appeal. The industry employs about 45,000 mostly female employees. A major threat to its stability is the 43 percent HIV prevalence among these women.

The Apparel Lesotho Alliance to Fight AIDS (ALAFA) is a special factory-based intervention that provides workers with HIV testing, treatment and prevention services. It has received support from international organizations working to alleviate poverty and the mainly U.S. retailers that purchase Lesotho’s products. The program now includes almost all the garment factories in Lesotho. ALAFA faces the challenges of a conservative moral atmosphere, the female workers’ poverty and disempowerment, and the stigma of HIV. These factors have led to difficulties in reducing HIV risk, low HIV testing rates and late initiation of treatment. ALAFA is making progress in these areas through its peer-educator program and workplace medical clinics.

Getting Industry Involved in Health Care

Lesotho is an independent mountainous nation completely surrounded by South Africa. The two million Basotho living there are in the midst of an AIDS epidemic as calamitous as any seen in the region. But Lesotho’s small, homogeneous nature fosters creative solutions to the epidemic. ALAFA is one such innovation that focuses on Lesotho’s main industry. The group’s name, which is also the Basotho’s word for “to care for the sick,” symbolizes both its local roots and international connections. It has united the country’s garment factories and workforce, the largely U.S. brands that buy from these factories, and an international organization promoting southern Africa’s economic development. These entities work together to provide workplace-based HIV treatment and prevention services.

Basotho garment workers represent a highly concentrated at-risk or already HIV-infected population. They are a cohesive social group with broad connections to the entire community. At the same time, the factory owners have become increasingly concerned about the devastating impact HIV is having on the stability of their workforce. Moreover, the U.S. brands see that funding ALAFA’s work supports their reputation for corporate social responsibility.

There is no question that the HIV situation in Lesotho is dire. The United Nations estimates that about 22 percent of the adult population — or 270,000 people — is infected. The epidemic has pushed the average life expectancy down to 40 years. Without HIV, it would be around 66 years according to a U.S. Census Bureau projection. The reason for this dramatic cut in life expectancy is easy to find: Only about a quarter of Basotho needing antiretroviral therapy (ART) actually received it in 2007. Still that percentage has increased from the low single digits only three years earlier. HIV testing itself is rare: About 12 percent of Basotho knew their HIV status at the end of 2007. Again this figure represents a large increase over 2004. Even as HIV testing and treatment become more accessible, HIV fears and stigma remain a barrier to taking action.

When ALAFA conducted an anonymous HIV serosurvey among apparel workers in 2007, it found that 43 percent of those taking the test were HIV-positive. This is not a surprising result given that the majority of these factory hands are young women living in a high-prevalence urban environment. (Their male counterparts tend to migrate to South Africa for the mining jobs.)

On the Road to Responsible Competitiveness: ALAFA’s Origins

The Lesotho apparel industry, with its 40,000 to 45,000 employees, is an economic mainstay for this poor country. Its existence is fragile, however, because wages (at least $100 a month) are twice what they are in competing Asian nations such as China. The manufacturers are largely transplanted Chinese and Taiwanese companies that could easily move elsewhere. But the existence of a U.S. law, the African Growth and Opportunities Act (AGOA), has provided a special duty-free entrée into the U.S. market, giving Lesotho a competitive edge. From 2004-2006 the industry was hit from all sides. Most importantly, the international apparel quota system, known as the Multi-Fiber Agreement (MFA), ended in 2005. The result was a tsunami of Chinese exports. At the same time, the value of Lesotho’s currency was rising against the dollar. Finally, AGOA’s provisions were set to expire in 2007 and 2008. Employment shrank from 54,000 to 40,000, and a half dozen plants temporarily closed.

The U.S. Congress eventually extended AGOA to 2015, and Lesotho’s apparel industry rebounded. Coming up, though, is the 2012 expiration of a key AGOA provision that allows less developed countries like Lesotho to use fabric from the cheapest source, not just from Africa or the United States.

The international effort to recover from the demise of the MFA quotas garnered Lesotho considerable attention and contributed directly to the founding of ALAFA. The MFA recuperation effort became embodied in the MFA Forum, which holds meetings involving governments, international organizations, private corporations, trade unions and nongovernmental organizations. Andy Salm directs the textile and apparel program of ComMark Trust, a nonprofit group funded by the U.K. Department for International Development (DFID). Salm recounts, “We got companies and workers to go to places where the forums were held. This raised Lesotho’s profile.” ComMark’s goal is to restructure and expand certain trade sectors in southern Africa so that they work to alleviate poverty. Salm has been advising the Lesotho apparel industry since 2002.

One of Salm’s strategies was to carve out an “ethical manufacturer” niche for Lesotho. “The industry had to clean up its act,” says Salm. “We had to assure the international brands that if you bought from Lesotho, there would be no bad publicity — no sweatshops, no labor law violations... HIV became one of the issues that allow brands to show that they are addressing the well-being of the people in the industry.” Salm and ComMark obtained seed money from DFID and the Lesotho government to launch an apparel factory-based HIV control program. This money went to hire three South African consultants to write a feasibility report on the concept. Also, Dagmar Hanisch was hired as project implementation team leader and remains ALAFA’s director of policy and prevention.

The MFA Forum made Lesotho one of its priorities. In May 2006, ComMark and the MFA Forum hosted an international gathering in Maseru, the capital of Lesotho. The meeting was dubbed “Destination Lesotho: On the Road to Responsible Competitiveness Conference.” It included United Nations (U.N.) and government officials as well U.S. garment brands, local manufacturers and union representatives. A gala dinner at the conference proved to be a suitable occasion to launch ALAFA in the glare of international publicity.

Among the attendees at the conference and ALAFA launch was the singer Bono, who developed the concept of the “Product (RED)” clothing line. Product (RED) corporate members donate part of the profits on their (RED) products to the U.N.’s Global Fund to Fight AIDS, Malaria and Tuberculosis. One Product (RED) member, the U.S. company Gap Inc., agreed to fund an ALAFA pilot program at the 4,500-person Precious Garments facility from which it sources both (RED)- and Gap-branded items. Edun, another Bono ethical apparel spin-off, began producing its own “ONE” T-shirt whose purchase price included a $10 donation for ALAFA. In November 2006, ALAFA received a $276,000 check from this source.

ALAFA Today

Gap and Edun have continued to support ALAFA, with additional support from such U.S. buyers as Levi Strauss, Wal-Mart and Nordstrom. Cathy Dix, Gap’s corporate social responsibility manager for sub-Saharan Africa, says, “Gap Inc. supports the ALAFA program because of its innovative and scalable approach to addressing the HIV/AIDS pandemic. ALAFA is a unique intervention in that it is a holistic, industry-wide initiative covering prevention, treatment and care for those infected with the HIV virus. It is a proven model that has changed the lives of thousands of garment workers, both male and female.” The major portion of ALAFA’s continuing funding has come from the UK’s DFID, with other large grants from the European Union and the Irish government.

Three years after its founding, ALAFA has expanded to 30 factories covering 90 percent of the apparel workforce. That expansion took some convincing. Bart Vander Plaetse, ALAFA’s CEO says, “We started out with the two more-concerned companies, but the buyers encouraged the others to join. The other companies had to see the economic advantages. They now understand that ALAFA creates a healthier and more stable workforce. They see they have a greater chance of getting new orders.” ALAFA’s active support from international buyers and donors also showed the factories that ALAFA was a relatively low-cost way to enhance their sales appeal as ethical manufacturers. The textile and apparel exporters’ association now sits on ALAFA’s two oversight councils along with ComMark, government and trade union representatives, and the international buyers and donors.

Since the apparel industry works with ALAFA in a unified manner, it increases the potential for continuity of HIV care and education. Other workplace HIV programs in the region center on a single large business. The mining companies in South Africa, for example, provide HIV care and prevention services, but only regular employees receive HIV treatment. This leaves out the growing number of workers employed on a contract basis and employees’ families, which are usually distant from the mines. These standalone programs have little impact on community attitudes. Uptake of care is low even among the employees due to HIV stigma and fears of discrimination. Also, individual company programs can offer no continuity if the worker leaves the company’s employment for whatever reason, including ill health.

One factor mitigating some of the impediments is that the Aurum Institute has extended mining giant Anglo American’s comparatively comprehensive HIV care and treatment program to other workplace and community sites under the auspices of the Aurum Institute. The Aurum Institute was founded by an Anglo American subsidiary but became an independent nonprofit in 2005. Since then, extension of corporate programs to the broader community has become an increasing topic of discussion. That broader community contains about 5.5 million HIV-positive South Africans. At the end of 2008, a mere 5,200 were receiving anti- HIV medications through Aurum’s 34 work-site programs, most of them still related to Anglo American.

Testing: The ALAFA program consists of three in-house components: HIV testing, treatment and prevention. Testing is crucial because it provides the link to treatment, which is lifesaving. Yet Basotho have shown considerable resistance to HIV testing. A government campaign, called “Know Your Status,” has met with only limited success due to underfunding and poor organization. An underlying issue is the stigma attached to testing positive. Salm recalls, “One woman related that her friends treated her like a prostitute when she tested HIV-positive, but those people are all dead now.”

At one point in 2008, ALAFA ran a grocery voucher lottery to encourage testing uptake. The workers in the initial ALAFA factories are now 70 percent or 80 percent tested, says Vander Plaetse. ALAFA claims to have tested a total of more than 13,000 apparel workers as of May 2009. That is about 30 percent of the entire workforce.

Treatment: The availability of treatment is critical to encouraging testing. When workers see their colleagues dramatically recover after receiving antiretroviral therapy (ART), HIV testing becomes much more compelling. ALAFA originally thought to depend on the government clinics, which dispense free ART. These clinics are distant from the factories, though, and require long waits to see a doctor. A factory employee would lose a whole day’s work going to the government clinic. That is something she could ill afford and her employer would frown on.

ALAFA in response instituted a program of factory-based clinics. The manufacturers provide the facility and hire a nurse. ALAFA pays the doctors. By special arrangement, the government supplies ART without charge to these private clinics. The factory clinics also provide a range of general health services beyond HIV — employees do not have to be HIV-positive to make use of them. This feature allows HIV-positive employees to visit the clinics without publicizing their HIV status to the world. (The workers may also see the doctors at their outside offices to ensure that their HIV status is kept private.)

Employees who test positive for HIV are immediately linked to the care available at the workplace clinics. About 85 percent of the people diagnosed with HIV take advantage of these services. ALAFA clinics are available at 20 sites to about three-quarters of the apparel workforce, as of March 2009. They serve 3,500 HIV-positive workers, with more than 900 receiving ART. Median time on ART was only 13 months, again according to the March 2009 report. The treatment program’s overall success had yet to be demonstrated at that time.

ALAFA’s clinics have implemented the 2008 government guidelines, which specify starting treatment when patients’ CD4 counts fall below 350. Patients nonetheless have been starting ART at a median CD4 count of only 173. Patients are still entering treatment in a very debilitated state, which limits the treatment response rate. Presumably, this situation will improve as the treatment program matures. Treatment options are rather limited (mostly nevirapine plus two nucleoside analogs). That said, sharp increases in CD4 counts have occurred. ALAFA, in March 2009, reported that almost 90 percent of all ART-treated workers had attained CD4 counts above 200, the upper limit for an AIDS diagnosis.

Prevention: Peer educators run the ALAFA prevention programs, which cover nearly all garment industry workers. The goal is to train 500 such educators who, in turn, educate their fellow shopfloor employees, a goal that was three-quarters fulfilled by early 2009. The subjects covered in the educators’ training include basic HIV and AIDS information, relationship issues, family planning and communications skills.)  

Though generally sexually active, Basotho are usually reluctant to talk about sex, and most of them are Catholic. The HIV education represents a cultural breakthrough, not least because it is largely oriented around women’s issues. The material generally follows the ABC approach — abstinence, be faithful, use condoms. Vander Plaetse comments, “We are about to go large scale with a campaign that outlines the risks of multiple concurrent partnerships, stressing A and B messages. But we are realists. Safe sex messages and materials form a large part of our prevention program.”

A major issue is poverty and the resulting transactional sex that women use to get by (to pay the rent, for example). ALAFA’s 2007 HIV prevalence survey found that multiple concurrent sex partners (along with sexual transmitted infection symptoms and being the family’s sole breadwinner) appreciably increase female apparel workers’ risk for HIV.

A major constraint is the apparel workers’ cultural roots in an oral tradition, which necessitates the creation of mostly visual or easyto- read materials. Another problem is the short time periods that the companies allow workers to leave their jobs to attend employee sessions. Many companies try to fit HIV sessions into lunch periods, which is obviously not optimal.

Vander Plaetse says, “We aim at least one big interaction moment in factory. We’re getting a meeting once every two months. There are also mixed status support groups. At some factories, these meet every week, whereas in others, they are struggling to keep alive.” ALAFA is attempting to evaluate the effectiveness of its prevention program through a behavior change survey conducted in the first half of 2009. Results will be out later in that year. Vander Plaetse says, however, “I really want to have seroconversion numbers. People who tested negative last year and then seroconverted during our campaigns are a particular challenge — each one is a defeat.” ALAFA’s widescale HIV testing will yield information about seroconversion in previously negative testers. To improve future results, ALAFA is organizing posttest clubs to support HIVnegative persons in their efforts to stay uninfected.

A Challenging Economic Environment

Vander Plaetse notes, “We can empower the women for behavior change. Some go back to the homesteads, where the man is still boss. So now we have programs for the men, too.”

A major 2009 move is the expansion of the ALAFA programs to include spouses and children. As Vander Plaetse’s comment highlights, a rollout makes sense since the families function as an economic as well as a social and sexual unit. Frequently one member of the couple transmits HIV to the other, with the risk particularly high for male-to-female transmission. The virus can then infect newborns. Losing one of the parents to HIV is a tremendous economic and emotional hardship for the survivors. Having sick and dying children is also a great strain.

This rollout is taking place at a critical time. The South African mines are laying off many Basotho men due to the global economic downturn. Many will need HIV care and prevention counseling upon their return to Lesotho. Basotho garment factories may themselves cut back as the crisis progresses. ALAFA already has provisions to extend health care to laid-off apparel industry workers for six months or more. This interval will allow them to find alternative medical providers without interruption of care, though most will probably end up at the already crowded government clinics.

Fortunately, the first year of the downturn did not affect the Lesotho apparel producers as much as those in other countries. Garment exports to the United States dropped 11 percent, and the industry reduced its total employment by 2,000. “The Lesotho industry has shown a lot of resilience, more than I expected,” says Salm.
There is also the question of whether the international brands and other donors will be able to continue to support ALAFA at present levels. Salm remains confident. He says, “As long as industry is there and donors support it, the program will stay in place.

It’s a cost-effective way to deal with HIV, but it’s not within the factories’ capacity to pay for. The competition in this industry is cutthroat.” But ALAFA’s mainstay grant from DFID ends in 2011. Replacement funding is not yet apparent.

The Lesotho government is the supporter of last resort since it will have to deal with the HIV epidemic if ALAFA doesn’t. David Rantekoa, formerly Lesotho’s principal secretary of trade and development and now ambassador to the United States, was instrumental in bringing the parties and resources together that founded ALAFA. He says that the government is committed to ALAFA’s program: “The government strongly believes that textiles are the driver of the economy, and it is absolutely crucial to pay attention to [the] well-being of workers in that industry.”

The Lesotho government’s proposed 2009-2010 budget calls for a 55 percent increase in health expenditures. It is difficult to exaggerate the low level at which the government is starting. The latest World Health Organization country report for Lesotho — issued in 2005 — described a grossly overstretched health system about to face the daunting burden of AIDS. Per capita health expenditures were only $28, and there was only one doctor for every 16,400 Basotho. Lesotho’s economy has grown considerably since then and so has the national health budget. Yet the 2009 health appropriation would still amount to only about $80 per person. Lesotho remains one of the poorest countries of the world, much poorer than neighboring South Africa but with an HIV crisis of equal extent.

ALAFA’s workplace strategy represents an efficient way to combat HIV in Lesotho and other poor countries with a concentrated industrial sector composed of medium-sized corporations. These companies are unable to develop HIV programs on their own although they have economic and public image reasons to do so. ComMark is considering transplanting the ALAFA model to Swaziland, another very poor country with a textile industry looking for an edge in its competition with South Asia. Yet the question of the model’s sustainability remains — securing stable funding will be critical in the years ahead.

By David Gilden