Fighting Nepal's AIDS threat
Surya B. Prasai
May 10, 2008
The Nepal Government´s Ministry of Health and Population recently released new figures stating that the total number of AIDS cases had gone down. The National Center for AIDS and STI Control (NCASC), Ministry of Health and Population, stated the figures could be around 69,790, close to the 70,352 numbers estimated by a study conducted in 2005. These figures somewhat contradict the views of international experts and past projections made on Nepal´s HIV/AIDS situation, namely that it is estimated every year 12000-15,000 people die due to AIDS related illnesses and the number of AIDS infections is multiplying day by day. Just adding these yearly deaths seem to make the Nepali official estimates sound alarming. Most donors in Nepal have ignored the plight of AIDS infected people, which is well exemplified by the recent case of two young school children in Biratnagar who were sent away from class after their status was made known public. It was a serious breach of human rights, and shows the stigma and discrimination still prevalent throughout Nepal when it comes to giving fair treatment to people living with HIV/AIDS. The situation is even more worse for Nepali women who have had to face huge gender bias in their daily lives and face social ostracism once their status is known.
In 2005, various UN and international organizations working in Nepal´s health sector stated to the Nepali and global media that national AIDS figure could rise to 150,000 -- about 1.5 percent of adults – if immediate interventions were not in place. The same sources warned, AIDS would be the main cause of deaths for the 15-49 age bracket within 10 years of the epidemic. The government envisaged the right steps would be taken: proper behavior change communications, putting in place an effective national communications strategy that would, in effect, support a proper government based national HIV/AIDS control plan, sufficient distribution of contraceptives for the vulnerable groups, clean needles for Nepal´s rising drug users, and Antiretroviral Treatment for those already suffering . So far, various donors have shown through their reports that they believe individual strategies, plans and logistics appear well placed to fight AIDS, but not everyone seems to be committed to the bigger picture, an overall coordinated plan under the Nepal Government´s initiative.
But does such a plan exist in truth? The National Center for AIDS/STI Control( NCASC) under the Ministry of Health and Population as the main center piece of action, faces coordination difficulties because it has very low skilled bureaucrats most of whom are political appointees, rather than technical experts who can tackle the multi-pronged crises. Expatriate advisers in particular those advising the Nepal Government do not seem to care about joint coordination efforts, thus leading to intensive donor competition. The problem is intensified by poor logistic resource mobilization and inability of the Nepal Government´s health sector staff to formulate programs that show exemplary leadership in tackling AIDS. Often foreign advisers seem to be doing the planning and executing their own projects without the Nepal Government´s knowledge. The actual truth expressed by Nepal´s prominent AIDS activists in various world AIDS blog sites point to the fact that a massive diversion of attention of health resources has gone towards organizing expensive seminars and foreign travel jaunts for Nepali civil servants than focusing on the crises, thus adding injury to insult among those infected and affected.
According to the Nepal Government, the new figures were released after the study was done using the latest available tools and methodologies. However, despite the Nepal Government publishing regular statistics, which to the best of its knowledge might be true, it appears a geographical resource gap does exist, which it fails to acknowledge on its website. The Nepal Government´s past directors in charge of the AIDS programs have openly acknowledged through various press statements that the figures could be two to three times the official figure, since Nepal´s civil conflict between 1996-2006 made it difficult to visit the remote regions. On the current figures released, the Nepal Government states 64,585 consist of adults between the age 15 and 49 years (with 16,387 of them women). Likewise, 1,857 are children below 14 years of age and 3,348 are adults above 50 years of age. The figures might be accurate in the government´s viewpoint, since that is the best it could avail during the survey period when Nepal was facing transitional political difficulties. The Director of the NCASC Padam Bahadur Chand states, "The number appears stable probably due to better technique of estimation used this time." That might be true, but it still does not hide the true reality of the AIDS spread in Nepal.
One should acknowledge in reading the latest Nepali AIDS projections that there is widespread illiteracy and ignorance of the disease in the isolated parts of the country. Less than 27.5 percent of Nepal's inhabitants can read, and a recent government survey conducted in the nation's 75 districts revealed that 71.7 percent of males and 49.6 percent of females had never heard of AIDS. Thus many might not have heard about the disease in the first place! There is little doubt that those who have the highest infection rates are needle-sharing drug addicts in urban locations, migrant workers who work in India, female commercial sex workers who are highly mobile due to the good transportation network , and their clients who appear to be younger and have more money to spend. In urban Kathmandu, Pokhara, and Biratnagar, the cash credit card and car symbol (the infamous 3 Cs) has caught the mood of younger generation Nepalis, who like to experiment a little with everything in life these days, including the availability of alternative entertainment and commercial sex. Drug use is on the rise in Nepal, particularly among the youth, while needle sharing is common which hugely sparks AIDS infection rates.
Despite the perceived stability in AIDS cases by the Nepal Government most foreign donors believe there is a lot of work to do in Nepal to curtail its further spread. More periodic surveys would definitely assist in understanding the adjustments to the National Operational Plan goals. New found political stability might assist in national agenda setting where AIDS could be more closely integrated to Nepal´s national development plans.
However, as the Nepali media writes on the issue almost daily, AIDS cases have been rising dis-proportionately – there has been an increment in infections among Nepal´s migrant worker population, younger age clients of commercial sex workers, female sex workers returning back to Nepal, and, those frequenting urban transportation network hubs such as bus drivers, passengers and bus assistants This all increases the national vulnerability threshold. Even considering the open trafficking of Nepali women and young girls across the border, where as many as 8,000-10,000 are sold in Indian brothels each year, the fact remains, the Nepal Government´s figures do not account for their return migration. Many of the Nepali women, who contract AIDS in Indian brothels are sent back to Nepal once their status is confirmed. Quite a few marry into Nepali village families, while others continue pursuing commercial sex work in Kathmandu, Pokhara, Dharan,. Biratnagar, Nepalgunj and other urban transport route hubs in Nepal.
The Nepal Government received last year US$ 76.5 million from the UN Global Fund and the money needs to be used to maximize reporting feedback inputs which the UN does require periodically. The United Nations Development Programme(UNDP) in Nepal coordinates the AIDS funding, which usually is handled by national governments and the responsible AIDS Coordinating Agencies elsewhere. The Global Fund amount was Nepal´s first major international assistance received in the field of HIV/AIDS in addition to regular and valuable funds dispensed through other agencies such as USAID, DFID and GTZ. Several UN agencies and INGOs also run substantive program interventions in HIV/AIDS prevention and control, which however focus on their individual program bent. The truth is, Nepal´s donors cannot be blamed for a lack of having a true perspective on what needs to be done in fighting AIDS. It is the Nepal Government that must be forthcoming on what it desires, and choose the kind of assistance that will stop AIDS in Nepal.
Recently, Nepal went through a decade long civil conflict and the country has just recently concluded a national Constituent Assembly Poll on April 10 which was considered a success by several international observers. Therefore, the new Nepal Government whenever it is formed has to implement the desired steps to evolve an all inclusive democratic future for all Nepalis, which must integrate major health and education challenges. It has been frankly stated by Nepal´s Prime Minister Girija Prasad Koirala that Nepal´s major impediment to progress is not democracy, rather the solvency of health and education problems on an urgent basis.
One should not forget, in Nepal´s 10 year civil conflict, 13,600 Nepalis died and 400,000 children and 900,000 adults were reportedly displaced, of which nearly 60% were from the remote Western and Far Western hilly region. However, every year due to AIDS, more than 15,000 Nepalis are dying, and no one among Nepal´s politicians seems to be raising eyebrows on why it is spreading so fast. Thus, it is a matter of national concern that the Nepal government opened up to this serious problem of rising AIDS infections. Concrete results should have been there by now, but so far the rhetoric seems to mismatch the poor ground results. Also, Nepal´s free press must stand its ground and report the accurate truth on AIDS in Nepal and how it might be stopped through effective social and community mobilization, besides media networking.
In 2005, various UN and international organizations working in Nepal´s health sector stated to the Nepali and global media that national AIDS figure could rise to 150,000 -- about 1.5 percent of adults – if immediate interventions were not in place. The same sources warned, AIDS would be the main cause of deaths for the 15-49 age bracket within 10 years of the epidemic. The government envisaged the right steps would be taken: proper behavior change communications, putting in place an effective national communications strategy that would, in effect, support a proper government based national HIV/AIDS control plan, sufficient distribution of contraceptives for the vulnerable groups, clean needles for Nepal´s rising drug users, and Antiretroviral Treatment for those already suffering . So far, various donors have shown through their reports that they believe individual strategies, plans and logistics appear well placed to fight AIDS, but not everyone seems to be committed to the bigger picture, an overall coordinated plan under the Nepal Government´s initiative.
But does such a plan exist in truth? The National Center for AIDS/STI Control( NCASC) under the Ministry of Health and Population as the main center piece of action, faces coordination difficulties because it has very low skilled bureaucrats most of whom are political appointees, rather than technical experts who can tackle the multi-pronged crises. Expatriate advisers in particular those advising the Nepal Government do not seem to care about joint coordination efforts, thus leading to intensive donor competition. The problem is intensified by poor logistic resource mobilization and inability of the Nepal Government´s health sector staff to formulate programs that show exemplary leadership in tackling AIDS. Often foreign advisers seem to be doing the planning and executing their own projects without the Nepal Government´s knowledge. The actual truth expressed by Nepal´s prominent AIDS activists in various world AIDS blog sites point to the fact that a massive diversion of attention of health resources has gone towards organizing expensive seminars and foreign travel jaunts for Nepali civil servants than focusing on the crises, thus adding injury to insult among those infected and affected.
According to the Nepal Government, the new figures were released after the study was done using the latest available tools and methodologies. However, despite the Nepal Government publishing regular statistics, which to the best of its knowledge might be true, it appears a geographical resource gap does exist, which it fails to acknowledge on its website. The Nepal Government´s past directors in charge of the AIDS programs have openly acknowledged through various press statements that the figures could be two to three times the official figure, since Nepal´s civil conflict between 1996-2006 made it difficult to visit the remote regions. On the current figures released, the Nepal Government states 64,585 consist of adults between the age 15 and 49 years (with 16,387 of them women). Likewise, 1,857 are children below 14 years of age and 3,348 are adults above 50 years of age. The figures might be accurate in the government´s viewpoint, since that is the best it could avail during the survey period when Nepal was facing transitional political difficulties. The Director of the NCASC Padam Bahadur Chand states, "The number appears stable probably due to better technique of estimation used this time." That might be true, but it still does not hide the true reality of the AIDS spread in Nepal.
One should acknowledge in reading the latest Nepali AIDS projections that there is widespread illiteracy and ignorance of the disease in the isolated parts of the country. Less than 27.5 percent of Nepal's inhabitants can read, and a recent government survey conducted in the nation's 75 districts revealed that 71.7 percent of males and 49.6 percent of females had never heard of AIDS. Thus many might not have heard about the disease in the first place! There is little doubt that those who have the highest infection rates are needle-sharing drug addicts in urban locations, migrant workers who work in India, female commercial sex workers who are highly mobile due to the good transportation network , and their clients who appear to be younger and have more money to spend. In urban Kathmandu, Pokhara, and Biratnagar, the cash credit card and car symbol (the infamous 3 Cs) has caught the mood of younger generation Nepalis, who like to experiment a little with everything in life these days, including the availability of alternative entertainment and commercial sex. Drug use is on the rise in Nepal, particularly among the youth, while needle sharing is common which hugely sparks AIDS infection rates.
Despite the perceived stability in AIDS cases by the Nepal Government most foreign donors believe there is a lot of work to do in Nepal to curtail its further spread. More periodic surveys would definitely assist in understanding the adjustments to the National Operational Plan goals. New found political stability might assist in national agenda setting where AIDS could be more closely integrated to Nepal´s national development plans.
However, as the Nepali media writes on the issue almost daily, AIDS cases have been rising dis-proportionately – there has been an increment in infections among Nepal´s migrant worker population, younger age clients of commercial sex workers, female sex workers returning back to Nepal, and, those frequenting urban transportation network hubs such as bus drivers, passengers and bus assistants This all increases the national vulnerability threshold. Even considering the open trafficking of Nepali women and young girls across the border, where as many as 8,000-10,000 are sold in Indian brothels each year, the fact remains, the Nepal Government´s figures do not account for their return migration. Many of the Nepali women, who contract AIDS in Indian brothels are sent back to Nepal once their status is confirmed. Quite a few marry into Nepali village families, while others continue pursuing commercial sex work in Kathmandu, Pokhara, Dharan,. Biratnagar, Nepalgunj and other urban transport route hubs in Nepal.
The Nepal Government received last year US$ 76.5 million from the UN Global Fund and the money needs to be used to maximize reporting feedback inputs which the UN does require periodically. The United Nations Development Programme(UNDP) in Nepal coordinates the AIDS funding, which usually is handled by national governments and the responsible AIDS Coordinating Agencies elsewhere. The Global Fund amount was Nepal´s first major international assistance received in the field of HIV/AIDS in addition to regular and valuable funds dispensed through other agencies such as USAID, DFID and GTZ. Several UN agencies and INGOs also run substantive program interventions in HIV/AIDS prevention and control, which however focus on their individual program bent. The truth is, Nepal´s donors cannot be blamed for a lack of having a true perspective on what needs to be done in fighting AIDS. It is the Nepal Government that must be forthcoming on what it desires, and choose the kind of assistance that will stop AIDS in Nepal.
Recently, Nepal went through a decade long civil conflict and the country has just recently concluded a national Constituent Assembly Poll on April 10 which was considered a success by several international observers. Therefore, the new Nepal Government whenever it is formed has to implement the desired steps to evolve an all inclusive democratic future for all Nepalis, which must integrate major health and education challenges. It has been frankly stated by Nepal´s Prime Minister Girija Prasad Koirala that Nepal´s major impediment to progress is not democracy, rather the solvency of health and education problems on an urgent basis.
One should not forget, in Nepal´s 10 year civil conflict, 13,600 Nepalis died and 400,000 children and 900,000 adults were reportedly displaced, of which nearly 60% were from the remote Western and Far Western hilly region. However, every year due to AIDS, more than 15,000 Nepalis are dying, and no one among Nepal´s politicians seems to be raising eyebrows on why it is spreading so fast. Thus, it is a matter of national concern that the Nepal government opened up to this serious problem of rising AIDS infections. Concrete results should have been there by now, but so far the rhetoric seems to mismatch the poor ground results. Also, Nepal´s free press must stand its ground and report the accurate truth on AIDS in Nepal and how it might be stopped through effective social and community mobilization, besides media networking.
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