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[NOTE: This is an UPDATE to a case study initially published in 2009. Read the original case study for appropriate context.]

Apparel Lesotho Alliance to Fight AIDS (ALAFA) is an innovative HIV prevention and treatment program based in Lesotho’s major industry. A large majority of workers in this small country’s clothing factories is female, and 40 percent test positive for HIV. The epidemic threatens to undermine this foreign-owned industry, which already faces heavy competition from low-cost Asian producers. ComMark Trust, a nonprofit group funded by the UK Department for International Development (DFID), focused on helping the Lesotho apparel producers garner a reputation for ethical manufacturing. Progressive HIV policies were a keystone of this effort to protect the industry, hence ALAFA. Beyond basic core funding from DFID, ALAFA was able to gain support from musical celebrity Bono and various retailers, such as the U.S.-based Gap chain.

Present Funding

In the past two years, ALAFA has had to rearrange its funding in the face of the global economic downturn. ComMark went out of existence after its five-year DFID grant ran out in 2008, and DFID’s final $1 million grant to ALAFA ended in March 2012. Bono’s involvement has also declined substantially, as has WalMart’s commitment. The European Union, a previous ALAFA funder, is taking up the slack through next March. While the EU and the German Development Bank coordinate plans for future funding, ALAFA continues to receive grants from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the Elizabeth Glaser Pediatric AIDS Foundation, and certain retailers such as Levi Strauss. Much of this funding is restricted to specific programs, such as condom distribution.

“In the coming year, we will be focusing on sustainability, with more local funding,” says Donna Bawden, ALAFA’s new executive director. “We will strengthen our relationship with the Ministry of Health, which now supplies drugs for treating HIV. We are also seeking increased buy-in from the factory owners, which now give space for clinics and make workers available for training.”

With 38,000 workers currently employed in ALAFA-covered factories, the organization is holding strong even though employment in the clothing and textile industry continues to decline. (It fell nearly 5 percent over 2009-2010, and losses from 2007 peak employment amount to 7,500 workers (17 percent).) ALAFA prevention programs reach more than 90 percent of industry workers, and 80 percent of employees in the garment plants have access to ALAFA’s factory-based clinics. In October 2011, the clinics reported 5,500 active patients.

HIV and TB Treatment

The rising unemployment makes treatment continuity a challenge. A further complication is that many of the textile workers have male partners working in South African mines. The number of such migrant workers is 14,000 (25 percent) lower than its 2007 peak. These men’s disrupted, stressful lives lead to high HIV rates. It makes sense to treat the family as a unit, and family members are eligible for treatment at the clinic physician’s private office (as are the workers themselves). Bawden notes, “We’ve always said that we wanted to treat the families, but we haven’t really had success in extending to families. Many of the family members are in faraway villages, and that’s where the workers go, too, if they lose their jobs.” ALAFA is working with the Lesotho Network of AIDS Service Organizations to strengthen a growing network of rural clinics.

The patients who remain within ALAFA’s clinics are now closely monitored for adherence. A medical tracking scheme developed for ALAFA provides doctors with laptop computers containing a database of all registered workers. The database records treatment history, and alerts medical staff when patients are missing visits. A nurse then investigates the reasons for such disappearances and ensures the continuity of care.

In addition to HIV, Lesotho has one of the most elevated rates of tuberculosis in the world, and a growing aspect of ALAFA’s treatment program concerns tuberculosis. It is important to integrate treatment for the two diseases since they make each other much more aggressive. Often the first sign of HIV is active tuberculosis. Nearly all the persons diagnosed with active TB in ALAFA clinics are also HIV-positive. International guidelines call for commencing HIV treatment in coinfected patients at the same time as starting TB therapy or soon after. As of October 2011, ALAFA clinics had treated 443 workers for TB of which 397 were currently receiving HIV drugs.

“We are really an HIV and TB organization,” Bawden says. Medical records for TB and HIV are tracked together, and the medical visits themselves are coordinated to reduce absenteeism. The result has been a high TB cure rate. So far, only 14 patients have died of TB-related causes.

Prevention

In 2007, ALAFA first studied HIV in a random sample of apparel workers and found an alarming 40 percent HIV prevalence. The same rate turned up in a 2009 study. However, the prevalence in women workers under 25, a somewhat better indicator of recent infections, had dropped substantially (from 37 percent to 29 percent). Notably, regular condom use had increased for both unmarried and married sexual partners, and the incidence of sexually transmitted diseases was half that in 2007.

ALAFA continues to adapt its prevention programs to have more of an impact on the epidemic. A U.S.-funded innovation is the addition of targeted peer education programs for female workers, male workers, and workers 25 years old and younger. These programs take into account their target’s social role. With men, the group discussion centers around what it means to be a responsible male: recognizing and avoiding high-risk sex, regular testing for HIV and keeping your family safe.

The program for young people involves developing male-female communication skills and HIV risk avoidance, including reducing sexual activity or delaying sexual debut. The women’s component concerns gender dynamics and communication in relationships. It examines the factors that contribute to HIV transmission and the problems faced by HIV-discordant couples. All three programs have a component on multiple concurrent partnerships, considered a factor in amplifying the African HIV epidemic.

ALAFA also conducts extensive multi-day training sessions for factory managers. Sessions are conducted in both the local Sesotho language and Mandarin Chinese. About 100 Lesotho-born and Chinese managers received HIV training in 2011. These trainings are vital to ensuring corporate understanding of the local HIV situation. They improve company support of ALAFA’s worker programs and improve the chances for financial sustainability.


By David Gilden