For inmates living with HIV, the most critical breakdown in Lesotho’s correctional facilities is not overcrowded cells or crumbling infrastructure — it is the absence of a small white pill that is meant to be taken every day without fail.
Antiretroviral Therapy (ART), the cornerstone of HIV treatment, is supposed to be uninterrupted. Yet an investigation by the Ombudsman, Advocate Tlotliso Polaki, reveals that access to life-saving medication remains inconsistent across the prison system, placing inmates at serious risk.
Advocate Polaki warns that correctional healthcare has reached a “critical threshold”, with inmates reporting frequent interruptions in treatment, largely due to recurring stock-outs of medication.
While the High Court case in Nyakane v Director of Public Prosecutions and Others (CRI/T/003/2018) explicitly affirmed the constitutional right to adequate healthcare for persons in state custody, this judicial mandate has not been effectively operationalised.
Adv Polaki notes that the current gap between legal standards and service delivery constitutes a significant risk to inmate health and a failure of state accountability.
She says the Lesotho Correctional Service (LCS) purports that antiretroviral drugs and anti TB drugs are supplied by the Ministry of Health at all four ART centres namely Maseru Central, Leribe, Mohale’s Hoek and Thaba Tseka and no reports of stock-outs had been recorded.
The LCS further submitted that patients in other facilities are registered with nearby health facilities where they get all their supplies at specified intervals.
“While we acknowledge challenges regarding referrals particularly in relation to remandees; interruptions hardly ever occur as these facilities say they always keep buffer stocks to cater for unexpected increase in the number of clients,” the organisation told the Ombudsman.
To resolve these inconsistencies and align with the High Court’s ruling, Adv Polaki called for the establishment of a dedicated procurement and distribution protocol between the Ministry of Health and the LCS to ensure ART supplies are prioritised and buffer stocks, like at Mohlomi Hospital, are always maintained to prevent shortages.
From a monitoring perspective, she called on the LCS to implement a monthly reporting mechanism where each facility head should certify the availability of essential medicines and any stock-out lasting more than 24 hours should trigger an emergency procurement response.
She also recommended that the LCS should develop an internal policy that holds facility administrators accountable for failing to uphold the judicial standards set in the Nyakane precedent.
This should be undertaken within a month of the issuance of this report, Adv Polaki recommended.
In facilities running at 194 percent capacity, where 971 men share space built for 500, a missed dose is more than a personal health risk, she warns.
The report warns that overcrowding, inadequate bedding, and poor hygiene create ideal conditions for disease transmission. Of the 971 at Maseru Central Correctional Institution (MCCI), 626 are convicted males while the other 345 are awaiting trial.
Lesotho continues to battle one of the highest HIV prevalence rates globally, with an estimated 22.7 to 26.6 percent of adults living with the virus. Approximately 240,000 people are currently on treatment.
That treatment gap sits inside a wider collapse. Of 78 recommendations the Ombudsman issued in 2023 to fix Lesotho’s correctional system, only eight (9 percent) were fully implemented. Partial progress was noted in just eight more, while the rest, 91 percent, remain entirely unaddressed.
In the same three years, Adv Polaki discovered that the prison population swelled 50 percent, from 1,835 to 2,757, against a national cell capacity of 2,811. The system-wide number masks the crisis: half of all 14 facilities remain overcrowded.
Remand detainees now make up 31 percent of the total — 868 people, consisting of 847 males and 21 females. Some have been waiting over eight years for trial. The convicted population is 1,889: 1,774 male and 115 female.
New arrivals, including those on ART, are placed in 14-day isolation carried over from COVID-19 protocols. The Ombudsman found it “often stretches into months,” cutting inmates off from exercise, sunlight, and family visits.
Medical isolation without daily clinical review violates the Mandela Rules, which cap such separation at 15 days, the report says.
For someone whose treatment depends on a clinic run that might be delayed, extended isolation is another barrier. The report calls the practice unjustified under current health guidance, creating a “restrictive environment with significant psychological risk.”
The report also shows that places where treatment is interrupted were condemned. Structural engineers in 2023 declared Berea, Quthing, Qacha’s Nek, Maseru Female, and the Juvenile Training Centre “unfit for human habitation” and recommended urgent demolition.
Three years later, all five still house inmates and staff. No reconstruction has begun.
“The numbers inside are stark. The Forensic Unit operates at 240 percent capacity — 84 inmates in a space for 35, up from 77 in 2023. MCCI is at 194.2 percent up 55 percent from 627 to 971. Mokhotlong’s population jumped 152 percent since 2023, from 36 to 91, for 120 spaces,” Adv Polaki notes.
The Female facility capacity doubled to 84 in a structure for 66, a 100 percent increase from 42. Even the Juvenile Training Centre, at 107 boys for 240 spaces, operates inside a building engineers said should be torn down, after a 67 percent rise from 64.
According to the Ombudsman report, Leribe now holds 311 inmates instead of 300, and Butha-Buthe is up 89 percent, from 81 to 153 for 168 spaces. Mafeteng rose 77 percent from 66 to 117 for 120. Thaba-Tseka is up 41 percent, from 62 to 87 for 160. Lepper is two over capacity at 32 inmates for 30 spaces, up 52 percent from 21. Quthing sits at 99 inmates for 66 spaces.
Qacha’s Nek saw the smallest increase at three percent, from 62 to 64 for 66, yet it too was condemned. Berea holds 225 inmates for 240 spaces, up 56 percent from 144, and still operating despite its condemned status. Mohale’s Hoek has 261 inmates for 534 slots, up 10 percent from 237, an exception in a system where overcrowding has worsened dramatically since 2023.
“Healthcare has reached a “critical threshold,” the report states, adding that pellagra, a disease of niacin deficiency, was reported in Mafeteng. Scabies outbreaks are recurrent while tuberculosis is rampant due to overcrowding and lack of hygiene supplies.
Adv Polaki implored the government to acknowledge the inherent complexities of correctional facilities and the necessity of targeted resourcing.
Given the distinct environmental, security, and humanitarian needs within correctional facilities, a specialised approach to resourcing is definitely required, she says.
“Neglecting this need leads to critical systemic failures, rendering rehabilitation programmes ineffective and endangering the safe custody of inmates. A failure to prioritise the specific needs of these institutions continues to undermine their operational stability and safety. The house of Lesotho’s correctional system remains in ruins. The question is no longer whether we will rebuild it, but whether we will allow it to collapse entirely upon those it holds, and upon those who hold them,” Adv Polaki pointed out.
The World Health Organisation’s guidelines on HIV in prisons are explicit: antiretroviral therapy must be “uninterrupted,” with the same standards of care as in the community. Rule 24 of the United Nations Mandela Rules, which Lesotho has endorsed, demands equivalence of healthcare. In practice, a missed dose in a cell at 194 percent capacity carries different stakes than in the community.
Overcrowding, poor ventilation, and malnutrition; like the pellagra reported in Mafeteng, accelerate progression and risk drug resistance. UNAIDS flags correctional facilities as potential “reservoirs” for resistant strains if treatment is unstable.
The report further revealed that the 1959 Prison Regulations mandate daily meat, vegetables, and milk for inmates. This has never been implemented since independence. Instead, the diet is porridge for breakfast and beans or peas for lunch and supper, year after year.
For immune-compromised inmates, including those on interrupted ART, malnutrition compounds the risk.
With Lesotho’s HIV and tuberculosis response heavily supported by international partners, instability in prison healthcare poses a broader public health risk. Inmates eventually return to their communities, potentially carrying untreated or resistant infections.
The Ombudsman’s report concludes with a stark warning: the crisis in correctional facilities is no longer just a matter of reform, but of urgent intervention.
