According to the World Bank:
Nepal is facing increases in HIV prevalence among high risk groups such as sex workers, injecting drug users (IDUs), men who have sex with men (MSM), and migrants. There is an urgent need to scale up effective interventions, especially among IDUs. Nepal's poverty, political instability and gender inequality, combined with low levels of education and literacy make the task all the more challenging, as do the denial, stigma, and discrimination that surround HIV/AIDS.
State of the Epidemic
The first case of AIDS in Nepal was reported in 1988. Since then, the numbers have risen among the country’s 27 million people. By the end of 2005, more than 950 cases of AIDS and over 5,800 cases of HIV infection were officially reported, with three times as many men reported to be infected as women. However, given the limitations of Nepal’s public health surveillance system, the actual number of infections is expected to be much higher. UNAIDS estimates that 75,000 people were living with HIV at the end of 2005.
Nepal’s HIV epidemic is largely concentrated in high-risk groups, especially female sex workers (FSW), IDUs, MSM and migrants. Injection drug use appears to be extensive in Nepal and to overlap with commercial sex. Another important factor is the high number of sex workers who migrate or are trafficked to Mumbai, India to work, thereby increasing HIV prevalence in the sex workers’ network in Nepal more rapidly.
Nepal’s epidemic will continue to grow if immediate and vigorous action is not taken and will be largely driven by injection drug use and sex work. Major risk factors are as follows:
Continued Spread among Injecting Drug Users: In most Asian countries, IDUs are the first community to be affected by HIV. Nepal was the first developing country to establish a harm reduction program with needle exchange for IDUs. However, due to the program’s limited coverage, the impact on HIV transmission has been limited. HIV prevalence among Nepal’s estimated 19,850 IDUs varies by location. 22% of IDUs are HIV positive in Pokhara, whereas 52%, 33% and 8% are HIV positive in Morang, Sunsari, and Jhapa districts respectively (FHI 2005). HIV prevalence among Kathmandu’s 5-6,500 IDUs has decreased from 68% to 52%.
Trafficking of Female Sex Workers: Due to their highly marginalized status in society, female sex workers in Nepal have limited access to information about reproductive health and safe sex practices. Cultural, social, and economic constraints bar them from negotiating condom use with their clients or obtaining legal protection and medical services. Almost 60% of their clients, who are mainly transport workers, members of the police or military, wage earners, and migrant workers, do not use condoms. While nationally, HIV prevalence among FSWs is 4%, infection rates among street-based sex workers in the Kathmandu valley are between 15-17%. Nationally, clients of FSWs have an estimated HIV prevalence rate of 2%. A major challenge to HIV control in the country is the trafficking of Nepalese girls and women into commercial sex work in India, and their return to Nepal. About 50% of Nepal's FSWs previously worked in Mumbai, India, and some 100,000 Nepalese women continue to engage in the practice there. It is estimated that 50% of Nepalese sex workers in Mumbai brothels are HIV positive (FHI 2004).
Changing Values among Young People: Young people are increasingly vulnerable to HIV due to changing values, group norms, and independence. Girls, even if they have knowledge about HIV/AIDS and other Sexually Transmitted Infections (STIs), do not have the means of protecting themselves due to their traditionally lower social status. Teenagers, although apparently highly aware of the HIV risk (based on behavioral surveys), do not necessarily translate this awareness into safe sex practices. A high prevalence of premarital sex exists, with 20% of teenagers considering it acceptable among young people.
High Rates of Migration and Mobility: Estimates of internal and external migration for seasonal and long-term labor range from 1.5 to 2 million people. It is necessary for the economic survival of many households in both rural and urban areas. Removal from traditional social structures, such as family, has been shown to promote unsafe sexual practices, such as having multiple sexual partners and engaging in commercial sex. A 2002 study suggests that HIV prevalence is nearly 8% in migrants returning from Mumbai.
Low Awareness among Men Who Have Sex with Men (MSM): Although accurate data on sex between men are not available, a recent report suggests that MSM activity in Nepal is not different from the MSM activities of the rest of the South Asia region. Current HIV prevalence among urban-based MSM is 4%. The knowledge of safe sex and condom use is low in this community. Furthermore, many men who have sex with men are also married, which puts their spouses at risk of becoming infected with HIV. The Blue Diamond Society is a Non-governmental Organization (NGO) founded in 2001 to address the needs of Nepal’s sexual minorities. It provides community-based sexual health, HIV/AIDS, and advocacy services for local networks of sexual minorities.
National Response to HIV/AIDS
Government and Institutional Framework: In 1988, the Government of Nepal launched the first National AIDS Prevention and Control Program. In 1995, a national policy was formulated, emphasizing the importance of multi-sectoral involvement, decentralized implementation, and partnership between the public, and the private sectors (including NGOs). It also called for coordinated monitoring and evaluation, promoting actions for safe practices, counseling, and services to people living with HIV and AIDS. Provisions were made for reducing stigma and discriminatory practices against people living with HIV/AIDS, confidentiality of blood testing, and safe blood transfusion.
Toward this effort, Nepal established a multi-sector National AIDS Coordinating Committee (NACC) chaired by the Minister of Health in 1992. More recently, a National AIDS Council (NAC) chaired by the Prime Minister was established to raise the profile of HIV/AIDS. The NACC reports to the NAC. The NAC was meant to set overall policy, lead national level advocacy, and provide overall guidance and direction to the program. The NACC, on the other hand, was expected to lead the multi-sector response, and to coordinate active participation of all sectors in the fight against HIV/AIDS. However, both the NAC and the NACC have essentially been non-functional. Each has met only once or twice and activating these entities is a great challenge. At the district level, District Development Committees are charged with implementing and monitoring HIV projects according to national strategies and guidelines.
The main governmental agency responsible for HIV/AIDS and STD is the National Center for AIDS and STD Control (NACSC) under the Ministry of Health and Population. The NCASC has developed a National Strategy on HIV/AIDS, which has subsequently been translated into a five year HIV/AIDS Operational Plan for 2003-07. Each year, an Annual Work Plan is developed; the Annual Work Plan and Budget for 2005-06 was developed in a participatory manner, involving a wide array of key stakeholders and thus it currently provides a common reference point for the national response. The strategy and operational plan seek to address management needs and define the resource requirements for an expanded response to HIV/AIDS in the country.
The government estimates a requirement of US$88 million for the National Operational Plan for 2003-07; the current Annual Plan indicates a budget of about $20 million, of which a financing gap of US$5.5 million has been identified. While available funds may not be sufficient, the lack of implementation capacity has hampered the utilization of the existing resources. USAID funds are, however, an exception as they are spent directly through non-governmental channels. Reorganizing the management mechanism to improve implementation is under discussion. One idea under consideration is the establishment of a semi-autonomous entity to oversee and coordinate the overall program. The currently weak capacity in NCASC, bureaucratic constraints inherent in the government system, and its inability to involve non-health sectors as well as NGOs effectively, would argue for such an entity. An institutional reform task-force that was
established in May 2005 has produced an options paper and the Government is actively considering its recommendations.
An antiretroviral treatment protocol has been endorsed by the Ministry of Health and Population, and treatment has been has been started on a limited basis. Initial focus, being undertaken with assistance from UNICEF, is on preventing mother-to-child transmission.
Non-Governmental and Community Based Organizations (NGOs & CBOs): Numerous private and voluntary organizations implement HIV/AIDS activities funded by donors. There are currently almost 100 NGOs working in the area of HIV/AIDS. NANGAN, a consortium of NGOs in Nepal, is working to coordinate and share information, education, and communication materials, experiences, and lessons learned. The National Network Against Girls’ Trafficking, a coalition of approximately 40 NGOs initially established to tackle the problem of girl trafficking, has also begun to address the issue of HIV.
The relationship and communications between the government and the NGO community, as well as among NGOs themselves, however, are not coherent. A private business collaborative group, called FNCCI, has signed a declaration of commitment and has designed an initial HIV/AIDS-at-workplace initiative with UNAIDS and the ILO.
Donors: A number of multi-lateral and bilateral organizations support HIV/AIDS prevention and control initiatives in Nepal, including interventions for vulnerable groups; behavioral change communications; condom promotion; STD control; testing and counseling; surveillance; and operational research.
USAID provides through its cooperating agencies the largest funding for HIV/AIDS interventions in Nepal, including surveillance activities, condom social marketing, as well as communication and advocacy programs.
The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) has approved a grant to implement the National Strategy over a period of four years. The focus is to be on young people and migrants, as well as on providing care and support to people living with HIV/AIDS. However, there was an implementation delay of more than two years after the funds were approved. This was mainly been due to the lack of a Management Support Agency (MSA). This problem was solved when UNDP was contracted to serve as the MSA, and the GFATM resources began to flow about a year back. More recently, UNDP is being proposed as a second Principal Recipient for the GFATM funds, thus making the fund-flow direct.
DFID committed a 5-year grant to support the HIV/AIDS program, based on gaps identified in the Annual Work Plan. This grant is also implemented through the same MSA which supports the GFATM-financed program, and includes a fast-track mechanism to contract NGOs rapidly, and a Challenge Fund mechanism to promote innovative ideas as well as a traditional procurement mechanism.
UNAIDS coordinates a theme group based in Kathmandu, and, between 1990 and 1999, the UN system supported the national response in Nepal with approximately US$5 million to build capacity, integrate HIV/AIDS into reproductive health services, and initiate a decentralized response. WHO has provided funds and technical support. Other donors include the European Union, Germany, and Switzerland.
A consortium of multilateral and bilateral donors (UNAIDS, UNDP, USAID, DFID, AusAid) collaborated with the government to address the issue of reducing the risk for female sex workers, their clients, and IDUs. Family Health International was the executing partner of the US$2.6 million project. Harm and risk reduction components included behavior-change communication; social marketing of condoms; harm-reduction equipment, such as clean needles and syringes; STI treatment; and drug substitution therapy. Support services, such as drug counseling, HIV care and support, voluntary HIV testing, and counseling, have been established. The project has ended and the various donor agencies involved are currently implementing separate programs, with significant room for improving their coordination mechanism. While the UN Theme group does meet fairly regularly, it does not include the major bilateral donors and the “Expanded Theme Group” has not been meeting regularly. More recently, an informal monthly lunch meeting has been started to supplement the formal mechanisms.
Issues and Challenges: Priority Areas
Addressing the HIV/AIDS epidemic in Nepal requires immediate action and long-term continuity and sustainability. The following actions are essential:
Emphasize HIV/AIDS as a development issue with continued high-level leadership. The epidemic cannot be tackled through medical/clinical interventions alone. HIV/AIDS prevention and control requires a multi-sectoral approach, involving sectors other than health, such as education, women’s affairs, information, law and order, defense, agriculture, labor and transport.
Demonstrate the need for an expanded and coherent response. Also strengthen management for effective collaboration and coordination between public and private sectors, and improve implementation.
Mobilize resources for scaling up responses for high risk groups. These include migrants, female sex workers, injecting drug users, and men who have sex with men.
Scale up advocacy, behavioral change activities, and health promotion interventions for young people, mobile populations, female sex workers, IDUs, and men who have sex with men.
Implement harm-reduction initiatives for IDUs and promote condom use in casual and commercial sex. Address opposition to scaling up harm-reduction measures such as the distribution of clean needles and syringes to IDUs.
Strengthen biological and behavioral surveillance to enhance understanding of the extent and nature of HIV and STIs, sexual behaviors, and healthcare-seeking behaviors related to HIV and STIs.
Encourage openness in addressing risky behaviors and to protect vulnerable populations. Denial and stigma of HIV and groups that are at high risk only hamper prevention efforts. Efforts to increase knowledge, reduce stigmatization, and promote positive attitudes and norms about safe sexual behaviors are critical.
Provide comprehensive care for people living with HIV and AIDS, including widely available voluntary counseling and testing facilities, provisions for treating opportunistic infections, rolling out of quality structured treatment, and adherence to monitoring.
World Bank Response
The World Bank has provided the Government of Nepal with technical assistance in a variety of areas pertaining to HIV/AIDS. This includes updating the National Strategy, and integrating HIV/AIDS prevention into the country’s National Health Sector Program. It also covers issues related to STI treatment, blood safety, HIV surveillance, voluntary counseling and testing for HIV, and care and support of people living with HIV and AIDS.
The lack of a suitable institutional mechanism with adequate capacity and an appropriate mandate, effective multi-sectoral involvement, and strong public-private partnership, has been a key impediment to mounting an effective response to the epidemic so far. The Bank has enhanced its technical support to include specific assistance in removing this hurdle.