HIV in Nepal is extremely heterogeneous, with respect to the most‐at‐risk populations (MARPs), geographic distribution, and risk factors in different geographic regions. The epidemic is concentrated in key populations such as sex workers, injecting drug users (IDUs), men who have sex with men (MSM), and some migrants. Effective prevention interventions need to be scaled up among MARPs and their direct sexual partners. Nepal's poverty, political instability and gender inequality, combined with low levels of education and literacy make the task challenging, as do the denial, stigma, and discrimination that surround HIV and AIDS.
State of the Epidemic
The first case of AIDS in Nepal was reported in 1988. As of December 15, 2011, 19,118 cases of HIV infection were officially reported; however, given the limitations of Nepal’s public health surveillance system, the actual number of infections is thought to be higher. There are approximately 50,200 people living with HIV as of 2011 and that around60 percent of those infected are unaware of their sero‐status.
Nepal’s HIV epidemic is largely concentrated in MARPs, especially female sex workers (FSW), IDUs, MSM, transgender and some migrants to high risk districts in India. 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. About 58% of HIV infections among adults are accounted for by the key populations (IDUs, MSM, FSWs, male labor migrants and clients of FSWs).
Nepal’s epidemic will continue to grow if immediate and effective action is not taken. Major risk factors include:
-Injecting Drug Use: Nepal was the first developing country to establish a harm reduction program with needle exchange for IDUs. However, due to limited coverage, the impact on HIV transmission was also limited. In 2011, Nepal estimated the number of IDUs as between 30,155 and 33, 742. Injecting of pharmaceutical drugs is common. Poly drug use appears to be the norm, and transition from non‐injecting to injecting is linked to the cost effectiveness of injecting.
An estimated 939 IDUs are living with HIV or AIDS (about 2.2% percent of the total HIV cases). The burden of HIV among IDUs is heavy in the Highway Districts and Kathmandu Valley – where 30 percent of all PLWHA are IDUs. HIV prevalence among IDUs in 2011 in Kathmandu was 6.3 percent, significantly lower than 20.7 percent in 2009. This decline in prevalence is, to some extent, supported by improving behavioral indicators measured by three successive rounds of integrated biological and behavioral surveys (IBBS).
-Trafficking of Female Sex Workers: There are between 24,649‐28,359 female sex workers in Nepal with an estimated HIV prevalence of 1.69 percent. HIV infection rate among street‐based sex workers in the Kathmandu Valley is 4.2%. Due to their highly marginalized status, FSWs 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 percent of their clients mainly transport workers, members of the police or military, and migrant workers, do not use condoms. Nationally, clients of FSWs have account for 4.4% of total estimated HIV infections.
A major challenge to HIV control is the trafficking of Nepalese girls and women into commercial sex work in India. About 50 percent of Nepal's FSWs previously worked in Mumbai, and some 100,000 Nepalese women continue to work there. It is estimated that 50 percent 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 and group norms. Girls, even if they have knowledge about HIV and other STIs, often 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 always translate this awareness into safe sex practices.
-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 can promote unsafe sexual practices, such as having multiple sexual partners and buying sex. A 2002 study suggests that HIV prevalence is nearly 8 percent in migrants returning from Mumbai. As of 2011, the male labor migrants comprise of 27% of total estimated HIV infections in Nepal.
-Low Awareness among Men Sex Workers, Transgenders and their Clients (MTC): There are between 65,864 and 82,330 MTC in Nepal as per the national size estimation 2011. Knowledge about safe sex and condom use is low among Nepal’s MTC community; however progress is being made in terms of reach and behavior change. Comprehensive prevention programs among MTCs are being implemented by a federation of community based organizations in many districts of Nepal with the support of pooled funders (WB, DfiD, AUSAid, GAVI and KfW) of SWAp and UNDP/GFATM/FPAN. The expansion of services has resulted in better coverage, especially in urban areas. During the past five years, the coverage for MSM in Kathmandu has increased significantly: from 10 percent in 2004 to 66 percent in 2007 to 77 percent in 2009. Coverage of prevention interventions needs to be expanded to improve knowledge and to respond to the special service needs of MTC and stigma and discrimination need to be addressed as they continue to undermine efforts to increase the coverage of effective interventions.
National Response to HIV/AIDS
Government and Institutional Framework: In 1988, the Government of Nepal launched the first National AIDS Prevention and Control Program and in 1992 established a multi‐sector National AIDS Coordinating Committee (NACC) chaired by the Minister of Health. 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).
In 2002, 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. However, both the NAC and the NACC have essentially been non‐functional. 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 STDs is the National Center for AIDS and STD Control (NACSC) under the Ministry of Health and Population. The NCASC reviewed the previous National Strategy on HIV/AIDS (2006‐2011) and developed the National HIV/AIDS Strategy 2011-2016 which highlights prevention as a key strategic direction. The goal of this strategy is to attain universal access to HIV prevention, treatment, care and support with targets to 1) reduce new HIV infections by 50%, 2) reduce AIDS related deaths by 25% and 3) reduce new HIV infections in children by 90% by 2016. Moreover, the National AIDS Policy (1995) has been revised to inform the new “National Policy on HIV and STI, 2011”. The new policy highlights the roles and linkages of National AIDS Council, HIV/AIDS and STI Control Board (HSCB) and the NCASC. The HSCB was established in 2007 to enhance and expand the response to HIV and AIDS through, among other things, multi‐sectoral coordination. NCASC will continue to serve as the lead technical agency for surveillance, policy and technical guidance, capacity building of the health sector, and monitoring and evaluation of the health sector response. It will also assist with the mainstreaming of HIV and STI related activities within the sectoral programs of the MoHP and other line ministries.
The NCASC is in the process of developing a National M & E framework for ensuring harmonization of national and global indicators. It has established an institutional arrangement to collect, collate and disseminate information in order to support decision making, planning and implementation of strategic activities.
Non‐Governmental and Community Based Organizations (NGOs & CBOs): There are currently almost 100 NGOs working in the area of HIV/AIDS in Nepal and numerous private and voluntary organizations implement activities funded by donors. As a result, the relationship and communications between the government and the NGO community, as well as among NGOs themselves, are not coherent.
Donors: A number of multi‐lateral and bilateral organizations support HIV/AIDS prevention, care and support and treatment initiatives in Nepal, including interventions for vulnerable groups; behavioral change communications; condom promotion; STD control; testing and counseling; surveillance; and operational research. Financing for HIV/AIDS services has been provided by, among others, Family Health International (FHI), USAID and the Global Fund, and has been mostly managed by UNDP and FHI. Presently, the pooled funders in the SWAp have financed for preventive services for the targeted populations.
Issues and Challenges: Priority Areas
Addressing the HIV epidemic in Nepal requires immediate action and long‐term continuity and sustainability. The following actions are essential:
-Use data (e.g. behavioral and size estimation) to enhance strategic prioritization and resource allocation.
-Demonstrate the need for an expanded and coherent response. Also strengthen management for effective collaboration and coordination between stakeholders (government, development partners, NGOs, etc.) and improve implementation.
-Expand coverage of interventions and improve the quality and effectiveness of services provided to MARPs including female sex workers, injecting drug users, and MTCs.
-Scale up advocacy, behavioral change activities, and health promotion interventions for young people, mobile populations, female sex workers, IDUs, and MTCs. Community based organizations have to be strengthened to take up these activities.
-Implement harm‐reduction initiatives for IDUs and their partners and promote condom use in casual and commercial sex. Address opposition to scaling up comprehensive harm‐reduction measures such as the distribution of clean needles and syringes to IDUs.
-Strengthen biological and behavioral surveillance to enhance understanding of HIV, sexual behaviors, and healthcare‐seeking behaviors related to HIV and STIs.
-Encourage openness in addressing risky behaviors and protect vulnerable populations. Efforts to increase knowledge, reduce stigma, and promote positive attitudes and norms about safe sexual behaviors are critical. There is an immediate need to push the HIV bill to create an enabling environment
-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 and AIDS. This includes updating the National Strategy, and integrating HIV 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 Bank has committed financial support to the Government of Nepal to respond to HIV and AIDS through the Second HNP and HIV/AIDS Project (US$129.15 million), its overall support to the second phase of the Nepal Health Sector Program (2010‐2015).
The National Center for AIDS and STD Control (NCASC) is responsible for the implementation of the response to the HIV epidemic through MOHP’s network of health facilities and health workers, and for the contracting out of NGO‐delivered services to reach MARPs with effective prevention, diagnosis and treatment services in their own communities. The HIV/AIDS and STI Control Board (HSCB) is responsible for the coordination of the overall national multi‐sector response, policy formulation, and strategic planning.