Containing HIV/AIDS In Nepal
More Resources Needed

By Mahesh Sharma

JUST a few weeks before the international AIDS conference in Durban, South Africa in June, Finance Minister Mahesh Acharya presented national programme, development priority and budget in the Parliament for the year 2000/2001 where a mention of HIV/AIDS was made very explicitly. The Finance Minister, in his speech, expressed the willingness of the government to give due attention to issues like HIV/AIDS. Invariably, such budget document is just not about the numbers and figures, it is the reflection of policy, priority and commitments of the government. Whether such speech is made with full preparation and homework is yet to be proved, but if considered seriously and taken up by the policy makers such remarks can make a significant difference in the way HIV/AIDS issues are perceived and dealt with at the higher level. Interesting enough non of the MPs however, asked question or raised any issues about HIV/AIDS in the last session of Parliament. In a way, this tells about the homework or seriousness of the policy makers on the subject matter.

Strategy

A twelve point National AIDS policy developed in 1994 followed by a 5-year strategy (1997-2001) is very explicit on the overall direction of the government. However, despite the explicit statement in first policy "the government will give high priority to HIV/AIDS" — and the second point with categorical statement on multisectoral approach to HIV/AIDS by integrating HIV/AIDS issues in other government ministries and programmes, the achievement so far has not been satisfactory. The budget speech therefore, further prompted the need to examine the commitment and efforts made by the government to translate the policy into the actual action.

One of the indicators of such commitment is the actual budget allocated for containing HIV/AIDS activities. The total budget estimate is about Rs 750 million, out of which approximately Rs. 1.6 million is from regular budget and rest is anticipated to be met from donors mobilisation. Rs 1.6 m has been a standard allocation to National Centre for AIDS and STD Control (NCASC) for last few years despite its requests for increased allocation for intensified national AIDS control programme. One can easily guess now with such a meagre amount what can be achieved. This is a typical pattern of budget war prevalent between line ministries and Ministry of Finance, where implementing agency demand more and Finance Ministry uses its authority to slash the budget. The standard eadymade answer for this is always the same, which is, there is enough donors money available why should the government spend its resource to HIV/AIDS. Corollary to this is the inadequate national capacity to analyse and respond appropriately and timely to the epidemics, which never receive serious attention for strengthening including the capacity of NCASC.

As for the donors’ allocation or external assistance pouring in the country is concerned, making realistic estimates of such assistance has not been possible. Despite many past efforts to estimate total esource flow in the country for HIV/AIDS, the task remains undone for various practical and procedural reasons. Nevertheless, many NGOs, INGOs and others agencies do have HIV/AIDS activities either in integrated from or specifically focused on certain geographical area or on specific groups. Such efforts definitely need to be intensified so as to have wide coverage and impact. Clear policies, political will, supportive attitude from different organisations including government line agencies play a significant role for a co-ordinated and nationwide response. Experiences in other countries have clearly shown that political will co-ordinated effort is a must for the control of the epidemics. But here due to lack of political will and desire to strengthen the national capacity coordinated multisectoral response has not been very effective.

The current official figure of about 1600 HIV/AIDS is just a tip of iceberg. The UNAIDS estimates of people living with HIV/AIDS in Nepal is about 33,000. What is most disturbing is the accelerating trend of HIV infection and shift of epidemic from high risk behaviour groups to general population. Since the epidemic in Nepal is still at the ‘concentrated stage’ i.e. high HIV prevalence among certain high risk behaviour group, there is ‘window of opportunity’ of 3-5 years to act so that the spread of virus to general population is controlled. Widespread poverty, ignorance, low status of women and other gender related discrimination, poor access to health and development services are the fertile ground for rapid expansion of HIV/AIDS. Poverty stricken South Asian countries including Nepal provides a perfect environment for the growth of HIV. In India, the infection has already crossed the boundary of four million. With open border and major economic and social relation, as well as work migration and girl trafficking to India, the escalating HIV epidemic in India would have a profound implication of Nepal. It is as if sitting on a ticking bomb which could explode any time. The social and economic impact of the disease is very far reaching. The human suffering, discriminations, orphans and misery of children, loss of social capital, impact on education and national economy are already seriously felt by many countries. If we do not learn from others experience and act now , the only option left will be the same fate through which many African countries are passing on.

Commitment

The question here therefore, is not so much on the donors’ interest and the resources but on the political will and commitment of the government to address the epidemic. It is an inrealistic assumption on the part of the government that saying few words in front of the parliament will intensify the AIDS control programme and guarantee the donors’ increased assistance. The intention of the government must be seen to be translated into action and should be visible. In other words, this (the political will) is perhaps a precondition for increased donors’ support if that is what is anticipated. The present commitment of the government for AIDS controls is precarious the government has yet to double the amount of funds to serious problems like HIV/AIDS. While the whole world is dead serious on HIV/AIDS issues as reflected in plan, policies, and resources allocation of many countries, is this the seriousness and indication of the commitment of policy makers to combat the devastating epidemic like HIV/AIDS in Nepal?

The Changing Face Of AIDS

By Justine Sass & Sara Adkins-Blanch

THE AIDS epidemic is increasingly female, young, and poor. The rate of infection among women has increased each year since the early 1990s and continues to grow. Young women are the fastest growing group of people infected with HIV—50 per cent of them are between the ages of 15 and 24. Also more than 90 per cent of women with HIV/AIDS live in the less developed world. These women are, however, more than just statistics. As one HIV-positive woman from Zambia put it, "Do I look like a figure or a statistic? I am a person, a woman living with HIV".

The face of AIDS is increasingly female.

By the end of 1999, 33.6 million adults were living with HIV/AIDS, 14.8 million of whom were women. Though the numbers suggest lower infection rates for women, a closer examination highlights the growing HIV infection rates among women and the challenges these scenarios pose.

Examples, can be found in both the more developed and less developed worlds. In Spain, women’s share of reported AIDS cases more than doubled between 1985 and 1995, from around 7 per cent to 19 per cent. Brazilian women have experienced an even more spectacular increase in risk. In 1986, there were 16 men with HIV/AIDS for 1 woman; in 1997, there were 3 men for 1 woman. In sub-Saharan Africa. The region hardest hit by the AIDS pandemic, there are 6 HIV-positive women for every 5 men. As Dr. Peter Piot, executive director of the Joint United Nations Programme on HIV/AIDS, explains, "new evidence clearly shows for the first time that women infected with HIV outnumber men. Some 10 years ago, it was hard to make-people listen when we were saying AIDS wasn’t just a man’s disease."

The majority of women have been infected through unprotected sex, especially in Africa and South and Southeast Asia. In some cases, women’s exposure to multiple partners, intravenous drug use, inscreened blood transfusions, and other high-risk behaviour has led to HIV-infection. In many cases, however, HIV infection is part of a long chain of transmission, beginning with husbands or boyfriends who had been infected through drug use, through relations with sex workers or other female sex partners, or by having sex with other men.

The face of AIDS is increasingly young. Today, UNAIDS calculates that more than 50 per cent of all new HIV infections around the world occur in children and youth between 10 years and 24 years old. Women are becoming infected at significantly younger ages than men. Luckily, there are some signs that young people are avoiding behavior that led their parents and older siblings to HIV infection. Since young people account for a large proportion of the population in many regions of the developing world, reaching youth before they become sexually active is key to fighting the epidemic.

Young girls are particularly vulnerable to the sexual transmission of HIV. While both young girls and boys engage in consensual sex, girls are more likely than boys to be uninformed about HIV, to be coerced or raped, or enticed into sex by someone older, stronger, or richer. As Antigone Hodgins of the International Community of Women Living with HIV/AIDS (ICW) explains "young women face most of the issues that women do, you just have to add 10 times more difficulty."

Increased incidence of HIV/AIDS in young women has led to an increase in transmission of the virus from mother to child as well. Since the start of the HIV epidemic, an estimated 3.8 million children have died of AIDS before their 15th birthdays, nearly a half million of them in 1999 alone. Another 1.3 million children are currently living with HIV; most will die before they reach their teens. In recent years, much has been learned about preventing HIV transmission from mother to child. However, many hurdles to implementing prevention programs on a large scale in the less developed countries remain.

The face of AIDS is increasingly poor. The overwhelming majority—about 95 per cent -of all people living with HIV/AIDS at the end of 1999 were in less developed regions. Sub-Saharan Africa, bears a disproportionate burden of the epidemic. Of the 34.3 million adults living with HIV/AIDS, 24.5 million live in sub-Saharan Africa. Obviously, HIV infection is not confined to the poor, but poverty has made an enormous contribution in the spread of the infection by creating a situation of vulnerability. A vicious cycle emerges, AIDS deepens the poverty of households and nations, and poverty favors the spread of HIV/AIDS.

"Breaking this cycle will require not only greatly increased investments in more effective HIV prevention and care, but also more effective measures to combat poverty," said Robert Heeht, UNAIDS Associate Director for Policy, Strategy and Research, at the worldwide AIDS 2000 Conference in Durban, South Africa.

Biological and socioeconomic factors contribute to women’s increased vulnerability to HIV infection. Women are physically more susceptible than men to HIV because of anatomical differences. Women are also at a greater risk of HIV infection if they have unprotected sex during menstruation, if they experience bleeding during intercourse, or if either partner has an untreated sexually transmitted infection (STI). STIs make women more vulnerable to HIV infection because they provide easier access to HIV. Tearing and bleeding during intercourse, whether from "dry sex" coerced sex, or prior genital mltilation also multiplies the risk of HIV infection.

However, the reasons for HIV infection often have less to do with biology and more to do with fundamental issues of power and control. Women’s vulnerability to HIV infection may be increased by economic or social dependence on men. As AIDS and Men editor Martin Foreman notes, it is usually men "who determine whether sex takes place and whether a condom is used." In situations of economic dependence, women’s ability to insist on condom use is further curtailed. If women refuse sex or request condom use, they may risk abuse and suspicion of infidelity, be abandoned or be forced to leave the house—alone or with their children.

This dynamic also controls the lives of many female sex workers and women who occasionally exchange sexual favors to provide for themsleves and for their children. While some are able to negotiate condom use or work in "100 per cent condom use." scenarios, many risk violence or loss of income if they request condom use.    Concerns over immediate survival often take precedence over the specter of AIDS looming in future.

To reduce women’s vulnerability and risk to HIV infection, women’s access to information and services must increase, but more importantly, structural changes are needed to redress the power imbalance between women and men. In the few countries that have programs on women and AIDS, the emphasis continues to be on education, counseling, partner, reduction, male condom promotion, and monogamy. The messages aimed at women often disregard the power imbalances that act as barriers to women’s active use of most of these options.

Successful programs that reduce the growth of the epidemic among women aim to empower women economically. Programs that reinforce women’s economic independence by strengthening existing training opportunities, credit programms, saving schemes , and women’s cooperative can be linked with AIDS prevention activities.

Governments’ commitment is key to addressing the epidemic, as are social mobilisation, resource availability, and other structural changes in health services.

Successful country-level efforts have highlighted that with political commitment, sufficient resources, and good information, sexual behavior can change, for example, men would use condoms. Yet the battle against HIV/AIDS is just beginning. Only more efforts like these will keep the face of AIDS from becoming increasingly female, young and poor.

AIDS/HIV: The New Trends

AIDS/HIV is reversing decades of progress in improving the quality of life in developing countries. It has slashed life expectancies and forces choices between health and dozens of other investments vital for development. If AIDS affects 5 per cent of the population, for example, total national spending on health will increase by 40 per cent.

AIDS Is the Number One Killer: Worldwide, 33.4 million people are infected with AIDS/HIV, including 1.2 million children. The incurable disease has claimed 13.9 million lives since the epidemic began, 3.2 million of them children. In 1998, 2.5 million people died of AIDS. Fully 30 per cent of all tuberculosis deaths are due to HIV/AIDS infections, and if those deaths are counted. AIDS in 2020 will be the single largest cause of adult death from infectious diseases.

AIDS Is Spreading Fastest in the Developing World: By 1990, AIDS had already caused more adult deaths than malaria in the developing world. By 2020, it will cause 37 per cent adult deaths due to infectious disease in those nations.

New infection rates are slowing in most of the industrialised world, but 5.8 million infections still occurred in 1998, 70 per cent of them in sub-Saharan Africa. A total of 22.5 million adults are infected there and 75 per cent of all adult deaths result from AIDS or AIDS-related diseases. The vast majority are age 20-50, the most productive years.

In Botswana 25 per cent of all adults are HIV-positive. In Zimbabwe and Namibia the rate is 20 per cent Zambia 19 per cent Swaziland 18 per cent and in several other African countries, 10 per cent or more Women, the most important agents of development, are especially vulnerable because of social and economic inequality. In Africa, women under 25 have the fastest—rising infection rate.

In South and Southeast Asia, 6-7 million people now live with HIV/AIDS, while another 1.2 million became infected in 1998.

AIDS has slashed life expectations in many developing nations. Average life expectancies increased from 40 years to 64 years by 1990 in most of the developing world. But AIDS has wiped out 2.3 of this advance in Burkina Faso and Cote d’ Ivoire.

Botswana’s 1990 life expectancy of 61 years has dropped to 47 years. In Zimbabwe, life expectancy was on course to reach 66 years by 2005, but because of AIDS, children born today can expect to live only 41 years. The population is expected to stop growing because of and by 2015 will be 19 per cent smaller.

AIDS Orphans Are a Growing Tragedy: More than 8 million children have lost one or both parents to AIDS since the epidemic began. In 23 countries studied by UNFPA, the number of these "AIDS orphans" is expected to double by 2000, and to reach 40 miillion by 2010. AIDS orphans typically suffer from malnutrition and are more likely to stop going to school, to have to support themselves and take on adult responsibilities in the home, and to leave home or lose their homes. Often they become street children. Girls may feel increased pressure to marry. In Uganda, where HIV infection rates have fallen and apparently leveled off, AIDS orphans are estimated to number 1.7 million.

Signs of Hope: Concerted government-led programs involving health education, promoting condom use and discouraging sexual promiscuity have slowed HIV infection rates in some poor nations including. Thailand, Uganda and Brazil.

In Thailand, a vigorous campaign involving brothels raised condom use to over 90 per cent. The number of patients with STDs other than AIDS has dropped dramatically, and the HIV infection rate among army conscripts has dropped from 4 per cent to less than 2 per cent.

In Nairobi, Kenya, a program that treated STDs of 500 prostitutes raised their condom use to 80 per cent and is estimated to have prevented over 10,000 infections per year among their clients’ clients wives and other partners.

In Brazil, condom sales rose from 406, 000 in 1991 to nearly 27 million in 1996.

UN Population Fund.