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Kathmandu Valley, Nepal

HIV/AIDS/STI Prevention

Dhaka, Bangladesh

Kathmandu Valley, Nepal

Analysis of Family Planning / HIV/AIDS Integration Activities within the USAID Population, Health and Nutrition Center
- by ww.advanceafrica.org

Epidemiological Data on HIV/AIDS Prevalence Among High-risk Groups

As part of the Asia and Near East Bureau's (ANE) Regional HIV/AIDS and Infectious Diseases Strategy, FY 2000-2006, empirical evidence is needed to address the problem of reaching young men with sexual and reproductive health information and program interventions.

Although Nepal has historically been viewed as a country with low HIV prevalence, recently it has registered marked increases in HIV/AIDS.  From the first case of AIDS in 1988, an incidence of 10,000 HIV-infected persons was estimated by 1994; between 15,000 and 20,000 by 1996; and 33,000 by the end of 2000.

The Joint United Nations Program on AIDS (UNAIDS) and the Ministry of Health (MOH) currently estimates 58,000 HIV-positive people in Nepal.  This is now the second highest HIV prevalence in South Asia, next to India.  The country has reached a concentrated epidemic status, with threatening signs that parts of the country may even be experiencing a generalized HIV epidemic.  Improved HIV, sexually transmitted infection (STI), and behavioral surveillance in Nepal have shown that epidemic levels have greatly increased in several most-at-risk population groups.

While USAID funding has contributed to significant reductions in behavioral risks and continued low HIV prevalence in intervention areas during the past five years, gaps in national prevention coverage have left several most-at-risk groups exposed to an escalating epidemic.  As noted in the USAID/Nepal HIV/AIDS Strategy 2001-2006, high prevalence rates have been found in female sex workers in Kathmandu, injecting drug
users and males who migrate to Mumbai in India.  Increased use of HIV/AIDS prevention and care practices and services by the most-at-risk groups (i.e., female sex workers and clients, injection drug users, men having sex with men and migrant males) is a strategic objective of the program.

An important cross-cutting theme is that 30-40% of the most-at-risk groups are under the age of 25, and therefore, all interventions need to focus on youth.  One study in Kathmandu revealed that 44% of 13-15 year olds and 56% of 16-18 year olds admit to having had premarital sex.  Young people predominate among injection drug users, men having sex with men, female sex workers and migrants.  Youth-oriented activities will ensure that young people find voluntary counseling and testing (VCT) and STI services friendly and accessible and that they receive appropriate, understandable information regarding HIV/STI risk and protective behaviors.  

The most recent data from the June 2002 final draft of the National Strategy on HIV/AIDS Nepal 2002-2006 provide the current data being used by HMG/N to draft their second five-year HIV/AIDS national strategy.  The data indicate that HIV prevalence among injection drug users varied between 49% and 68% in 2001.  Among surveys of female commercial sex workers, HIV prevalence was 15.6% in 2001, down from the 20% figure cited in 1999 in Kathmandu.  Prevalence among STI patients varied between 0.7% and 6.6% among STI patients, 0.28% to 0.48% among blood donors and 0.2% among blood donors and 0.2% among ANC patients.  A similarly conducted survey of family planning clinic attendees in Kathmandu in 1999 revealed an overall HIV prevalence of 0.3%.

Over the past six years, in USAID intervention sites, HIV risk behaviors have significantly declined.  Female sex workers report that use of condoms with their last client has risen from 34% in 1994 to 74% in 2001.  Furthermore, the results of a 1999 HIV/STI prevalence survey indicated that HIV prevalence is still low within the two populations surveyed:  3.9% among female sex workers and 1.5% among truckers.  The data  also show that that among female sex workers, the primary determinant of HIV infection was previous sex work in India: 17.1% of Nepalese sex workers who had worked in India were HIV-positive, and 50% were positive if they had worked in Mumbai.  Syphilis infection was also high within both groups, suggesting that STI and BCI interventions need to be continued and strengthened to increase and sustain condom use.

CATALYST-funded Formative Assessment

Heterosexual transmission?especially transmission through female sex workers and migrant males and including injecting drug use?has dominated the attention of researchers and public health advocates in Nepal.  At the same time, comparatively little attention has been given to M-M sex and the HIV/STI risk associated with this sexual behavior.  Due largely to the social stigma and public shame associated with this sexual behavior, the extent of M-M sex, its impact upon the sexual health of both men and women and the effective control and management of STIs/HIV has been largely ignored.  Yet the potential for M-M unprotected sex is high in Nepal.  Like the rest of South Asia, it is a male-dominated society where social and public spaces are primarily male and masculine.  While men gain their acceptance in society from being married and accepting their "duty" of sexual intercourse with their wives for procreation, access to a more expanded sex life often takes place directly outside the family with both men and other women.

At the request of the Office of Population of USAID, CATALYST Evaluation Officer, Paula Hollerbach prepared a paper for the Office of Population entitled "HIV/AIDS and Reproductive Health Among Men in Nepal and Its Impact on Female Partners and Children" during the second quarter of 2002.  The study concluded that:

  • Recent studies have revealed that syphilis is a serious risk factor for HIV acquisition in Nepal.  Truckers with untreated syphilis are ten times as likely to acquire an HIV infection as those without syphilis.  About one in ten truckers and one in two female sex workers (FSW) have a sexually transmitted infection (STI), usually syphilis or chancroid.  The latest STI data show that 1.3% of sampled pregnant women aged 15-24 attending antenatal clinics tested positive for syphilis from serological screening in 1997.  A combination of biological and social factors renders women particularly vulnerable to reproductive tract infections.  Pelvic inflammatory disease, resulting from untreated gonorrhea, chlamydia, and bacterial vaginosis, have profound long-term consequences, including infertility, ectopic pregnancy, chronic pelvic pain, and recurrent episodes.  RTIs are also important cofactors for HIV transmission.
  • The latest figures (2000-2001) on HIV prevalence show rates of 49 to 68% for intravenous drug users (IDUs), a slightly lower rate of 15.6% among FSWs in Kathmandu, .7 to 6.6% among STI patients, .28 to .48% among blood donors, and 0.2% among ANC clinic attendees in 2000.  No data could be identified regarding serologic testing for HIV and syphilis or gonorrhea for male sex workers.
  • Self-reports of ever-experience of STDs among Nepalese youth are underestimated in survey data, as are reports of sexual experiences with a non-regular sex partner.  The proportion ever having at least one sign or possible symptom of STIs is higher among girls than boys (girls 14%, boys 4%).  Among factory workers who had experienced at least one type of sign and symptom, slightly over one-fourth of them sought treatment.  It is discouraging to note that over three-fourths of the girls did not seek treatment for their STI-related problems and reported that they were too embarrassed to get check-ups.  Most at-home deliveries take place without any professional assistance, with 55% attended by relatives and friends.  Therefore, representative data on the extent of newborn syphilis or gonorrhea are not available.
  • In Nepal, as in other South Asian countries, the sexual culture is such that there is no firm division between men who have sex with men and those who have sex with women.  Estimates of the size of the M-M population in South Asia are impossible to calculate, due in part to secrecy surrounding this behavior, difficulty in identifying hidden populations, and the extent to which sexual boundaries between men can be readily crossed in certain contexts.  M-M sexual behaviors often begin in early adolescence and arise from immediate access, opportunity, need to meet their physical needs, and sexual preferences.  Due to strong social norms of marriage and family, most of the men who engage in M-M sex also have sex with women, and some are married.
  • Although knowledge of HIV/AIDS is pervasive within the general Nepalese population, there is little knowledge of HIV/AIDS among the small sample of M-M interviewed in Kathmandu.  Even those men who had heard of HIV and/or AIDS had poor understanding of the health issues involved.  High rates of unprotected sex (especially anal sex), low availability of high quality condoms and lubricants, and several reports of anal bleeding were reported.  At the time, there were no social and emotional support services in Nepal addressing male-to-male sexuality, HIV, and HIV transmission within a generalized HIV epidemic in Nepal.
  • Condom use among men who have sex with men in South Asia is dependent upon the type of partner.  Condom use is more frequent when either a self-identified sex worker or a non-identified one buys or sells sex than when these two categories of men have anal sex with a non-paying partner.  Consistent condom use is more likely when M-M buy sex from women, than when these two categories of men have anal sex with a non-paying partner.  Consistent condom use is more likely when M-M buy sex from women, than when they buy sex from men.  Lack of perceived risk to STIs and poor acceptability of condoms are cited as reasons for nonuse.  Research is needed on the precautionary measures, other than condoms, that men take to protect themselves and their male and female partners from STI/HIV infection and the treatment options they consider and encourage their partners to seek.


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