“Migrant Workers Are Most Vulnerable Population”
Dr. Ram Prasad Shrestha
Former director of National AIDS and STD Center, Dr. RAM PRASAD SHRESTHA, is
a well known surgeon. Having spent a long time in medical sector, Dr. Shrestha, who retired from the government service few years ago, is now watching health related problems closely. Dr. Shrestha, who introduced some noble ideas in prevention of HIV/AIDS, spoke to KESHAB POUDEL on various issues regarding the present state of HIV/AIDS. Excerpts:
You served as a director of National AIDS Center and worked in medical sector for a long time. How do you see the overall status of HIV/AIDS in Nepal?
There were all together 8888 persons detected positive till the end of February, 2007. However, there are 72,000 estimated infected population. Despite increase in distinct quantity, the positive detection has comparatively declined. According government data, among 2179 total tested cases, 714 or 32.2 percent were detected positive in 2003. Similarly, among 6230 tested, 20.5 percent were positive in 2004. Likewise, among 7654 tested,
16.13 percent were detected positive in 2005. In 2006, among 16890 tested, 15.8 percent
were detected positive. Our status is that of concentrated epidemic.
How alarming is the situation?
More you test, more people you will detect. The trends show that HIV/AIDS prevalence is going alarmingly high as the number of population infected by HIV is increasing drastically.
How about status of female?
The positive case among female is further alarming. Among total infected, 27.1 percent, 30.4 percent, 26.1 percent and 86.6 in 2003, 2004, 2005 and 2006 respectively were female. Out of female infectivity, housewife infectivity is alarmingly high. Out of female infectivity, 66, 64, 66 and 86.6 percent were housewives respectively during 2003, 04, 05 and 06 respectively. One of the most alarming trends is that the infections among the housewives have gone up. It is around sixty percent. The data of 2006 showed the infectivity among housewives has gone up with 80 percent.
Does reduction in detection mean the number of HIV infection has declined?
Proportionately, the detection rate has declined. I assume there is some positive impact. It is very interesting picture. The male female infection remains similar as it is around 30 percent in recent months. This is based on my four years of consecutive data analysis.
How do you see the gap between detected population and estimated population?
There is a huge gap as only 12 percent of estimated infection of 72,000 know their real status and total 88 percent of infected people do not know their status. Hence they are potential threat for spreading infection to general population.
What is the threat to general population?
Around 99.5 percent of adult population between ages of 15 to 49 years are non-infected - as our prevalence rate is 0.52 percent. Hence, the program should be focused to safeguard this population.
What is the rural-urban status?
Out of 72000 infected HIV positive, almost 64 percent come from rural areas of Nepal, which accounts for labor migrants and rural housewives. We know very little about them and there is a research gap which needs to be seriously addressed.
How do you find the commitment of the government?
Government has made adequate commitments in international forum but it is not serious to implement them. Apart from political agenda, political parties and government should focus on the agenda of HIV/AIDS, which now has become a development agenda. No
political force including Maoists have yet shown any interest to this burning social and developmental issue. Our program should be seriously focused to address this alarming trend revealed by these data.
From where are they infected?
This may be overlapping issue as number of sex workers categorized themselves as housewives are spreading the infection. When we ask question to sex workers what do they do, many of them reply that they categorize themselves as housewives. Most of the housewives were infected from their own spouse.
Are housewives protected?
They are not. As you know, the housewives do not have capacity in sex negotiation. Our studies have shown that women cannot compel husbands to use condom even in the case of infection. This is why women living in rural areas with high labor migration like in the districts of mid-west and far west are very vulnerable from infection. It is unfortunate to say that the HIV's prevalence is high in rural areas but the programs are urban-focused.
Who are the vulnerable groups?
IDUs, sex workers and clients of sex workers are vulnerable population. Migrant workers are most vulnerable population now. Most of the migrant populations are from rural areas and overwhelming majority of migrant workers go to India from far west and mid-west. In Mumbai, the infectivity among female sex workers is around 50 percent.
What is the status of children infected with HIV?
There have been increasing cases of infections of children up to five years of age in the past four years. This also increased because of increasing number of infection among housewives. Children are infected because of infection in their mothers.
What is the prevalence rate?
According to our estimate, our prevalence rate is about 0.5 percent of population that means 99.5 percent adult population are non-infected. If we target only infected persons, we cannot protect our community.
What should be done to prevent spread of HIV?
Our target must focus on how to protect 99.5 percent from the infected population of 0.5 percent. Is it not a challenge? I have not seen any policy maker and planner raising this issue. We estimate that 72,000 people are infected by HIV/AIDS. But only around 10 percent of the population can be detected to have infection. Ninety percent populations are infected but they don't know what their status is.
What do we need to do to encourage people to disclose their infections ?
We don't have aggressive agenda to compel people to reveal their infection status. We have been launching just orthodox programs. We have not done anything to reveal, extract and explore. One of the states in India has declared to provide discount coupons to those female sex workers who will agree for voluntary testing. This is a kind of incentive that will encourage people. They are given 10 to 20 percent discount in shops. We need to replicate those kinds of program in Nepal so vulnerable groups of women can be detected.
Where is the HIV infection concentrated now?
Most of the housewives infected by HIV are from mid-western and far western region. Around 70 percent of infected persons come from rural population. However,
we don't have any program in rural areas. Our present programs are urban-focused. In rural areas, NGOs have been working in limited manner as NGOs have their own focused group and focused area. For the housewives, there is no awareness generating programs. Besides, in our rural society, it is very difficult to approach women.
Don't you think the possibility of using Female Community Health Volunteers?
I think Female Community Health Volunteers (FCHV), whose number is around 45,000,
should be given role to generate awareness in rural areas. I also proposed that to be incorporated in HIV/AIDS awareness generating program. After giving training to FCHVs, they must be sent from house to house for health programs. When she visits the households, she can be encouraged to speak on HIV also. By successfully launching Vitamin A programs and anti-polio programs, FCHVs have already shown that they are capable to launch nationwide programs provided the training. After giving them training, they should be given role of counseling to those families whose males have gone to India for employment. FCHVs have easy access in rural households.
Why are FCHVs effective?
FCHVs are distributing condoms and generating awareness on family planning. They don't see discussing sexual relations as taboo. They can discuss risk behavior, sexually transmitted diseases and everything with women. This group can show the way to prevent mother-child transmission and infection of HIV.
How to mobilize the donor communities?
The time has come to discuss these issues with Nepal's development partners. For this our national program managers must understand where we stand now. We have formulated National AIDS Policy in 2002. The policy envisages many positive things such as formulation of National AIDS Council at central level under the chairmanship of prime minister, National AIDS Coordination Committee under the chairmanship of Health Minister and District AIDS Coordination Committee at district level.
How are the district level AIDS Coordination Committees (DACC) functioning?
It is unfortunate to say that there is no status report regarding District Committees. During my tenure I had tried hard to know the status. If we are considering decentralizing HIV/AIDS issues up to district level, DACCs need to be activated and strengthened. Right now only four or five districts have DACC - whose primary responsibility is to build networks and coordinate the programs. In many vulnerable districts, DACC has no existence. When there is no institution, how can HIV/AIDS prevention programs be
implemented.
How do you see the role of NGOs?
Some NGOs have been doing wonderful job but I don't think mobilization of donors’ fund through NGOs vertical program can effectively prevent spread of HIV/AIDS. Non-governmental organizations should be given role but there must be institutions to coordinate them. This is what DACC can do. Under provisions of Global Fund, eight districts have been identified to run the programs. Even if you want to run this program we need to have district level plan.
