Improving the HIV care cascade in Lesotho: Towards 90-90-90 – A research collaboration with the Ministry of Health


The 90-90-90 goals imply improved diagnostics and treatment for HIV-infected individuals. The project aims to link clinical and molecular research and infrastructural support with potential achievements to cut new HIV infections to a quarter.


About the project


In November 2014 the Joint United Nations Programme on HIV/AIDS (UNAIDS) declared the 90-90-90 targets for 2020 as an intermediate step towards ending the AIDS epidemic as a global health threat by 2030. These targets are that 90% of HIV-infected individuals know their HIV-status, of these 90% receive sustained antiretroviral therapy (ART), and 90% of these achieve viral suppression. This will result in a suppressed viral load (VL) in 73% of all HIV-infected persons globally. The UNAIDS estimate that achievement of the 90-90-90 goal will facilitate a reduction of new HIV-infections from presently 2 million to below 500’000 per year in 2020. The rationale of the 90-90-90 targets lies in the preventive potential of ART. Mathematical modelling concludes that universal ART-coverage could indeed stop the epidemic. In line with the UNAIDS strategy, the World Health Organization issued in September 2015 the recommendation that anyone infected with HIV should begin ART as soon as possible after diagnosis.

Such a “test-and-treat” strategy bears, however, also unprecedented challenges to resource-limited settings where HIV is still hyper-endemic. The Continuum of Care Cascade (“the Cascade”) involves all steps HIV-infected individuals have to take in order to achieve viral suppression. It therefore starts at knowing the HIV-status, continues with linkage to care after a positive HIV-test, initiation of ART, uninterrupted continuation of therapy (called “retention in care”), and leads to viral suppression documented through regular VL monitoring. In Sub-Sahara Africa this care cascade is still far from the 90-90-90 targets. According to UNAIDS in 2013 only 45% of individuals were aware of their HIV-status, 39% of diagnosed individuals received ART and 29% of infected individuals had achieved viral suppression. In addition, diagnostic means are still largely missing that would allow the necessary virus monitoring. Innovative, effective, and practical approaches for improving the treatment cascade are thus urgently needed.

Lesotho, a small landlocked, impoverished country surrounded by South Africa has the second-highest HIV-prevalence in the world, the highest HIV transmission rates in the region and one of the lowest ART coverages in Southern Africa.


The project involves operational, clinical and molecular research combined with infrastructural support, that jointly aim at improving the HIV care cascade towards reaching the 90-90-90 targets in Butha-Buthe, a district in Northern Lesotho. More specifically, observational and interventional studies address the following topics:

  • Improvement of linkage to care, retention in care and viral suppression after home-based HIV testing and counselling (CASCADE-trial (NCT02692027)
  • Roll-out of routine viral load monitoring and improvement of viral suppression among HIV infected individuals on antiretroviral therapy
  • New approaches for HIV-infected individuals who fail first-line ART
  • Establishing a molecular laboratory in Lesotho to conduct research on HIV resistance
  • Capacity building among health care personnel in Lesotho.


Impact is expected at the following levels:

  • Improvement of the HIV care cascade in the district of Butha-Buthe
  • Strengthened clinical, laboratory, and research capacity in Lesotho
  • Generation of scientific evidence from a resource-limited hyper endemic setting to inform future national and international HIV policies and guidelines

Geographic scope

  • Lesotho

Research consortium


  • Niklaus Labhardt, MD, MIH, Swiss Tropical and Public Health Institute, University of Basel, Switzerland
  • Glass, Tracy, PhD; Swiss Tropical and Public Health Institute, University of Basel, Switzerland
  • Klimkait, Thomas, PhD; Molecular Virology, Department of Biomedicine (DBM), University of Basel, Switzerland
  • Gupta, Ravi Shankar, MD; District Health Management Team of Butha-Buthe, Lesotho
  • Thin, Kyaw, MD, MPH; Research Coordination Unit, Ministry of Health of Lesotho, Lesotho
  • Fritz, Christiane, RN, MIH, SolidarMed, Swiss Organization for Health in Africa, Lesotho

Project link to project website and P3

  • Link to project website (see also right column)
  • Link to project on SNSF research database P3




Further information on this content


Dr. Niklaus Labhardt Swiss Tropical and Public Health Institute Socinstrasse 57 CH-4002 Basel +41 61 284 82 55