HIV/AIDS

The Threat Is Imminent

As the government agencies try to fight the relatively new disease, HIV/AIDS continue to spread among youths and high risk behavior groups. Since there is no cure, multisectoral approach to prevent the spread of the disease should be the top priority

-By BHAGIRATH YOGI

When Sharmila (not real name) went to collect report of the blood test at local Blood Transfusion Center in the eastern town of Biratnagar early this month, she felt as if the earth had shaken below her feet. She could not believe upon her eyes. The report said that her 30-year-old husband was an HIV-positive. "I had never thought even in my dreams that I would have to face such a great betrayal," said Sharmila, with her eyes full of tears.

According to Kantipur daily (Dec. 6, 1999),  Sharmila's husband was suffering from problems like body-ache, lack of appetite and lethargy for the last two months. She finally got admitted her husband at the Koshi Zonal Hospital last month. After preliminary check-up, the hospital sent her husband's blood samples for HIV-tests at the Blood Transfusion Center.    And, there was the bitter truth.

A mother of two children, Sharmila never suspected why her husband, a wood-seller, returned home late at night. Little did she know that her husband visited local brothels. "We were having physical relationship till two months back," said Sharmila. "I don't know if I myself and my children, too, are affected from the disease."

It has been a nightmare for Sharmila. Unfortunately, hundreds of unsuspecting housewives, like Sharmila, and their children have already contracted the dreaded virus or are on the verge of contracting it throughout the country. And, the trend is spreading quite fast, say experts.

According to the National Center for AIDS and STD Control, a total of 1376 persons have been identified as HIV positives by the end of November this year. Of them, 283 people have been found suffering from full-blown AIDS (Acquired Immuno Deficiency Syndrome). Since the HIV virus was first detected among four persons in 1985, a total of 139 people have died of AIDS, say officials.

But that could only be the tip of the iceberg. According to independent and non-governmental studies, some 25,000 to 30,000 people in Nepal are HIV positive now and the number could grow up to 50,000 by the year 2000. "The official estimates in Nepal do not show the extent of the problem as they are based on the blood samples voluntarily given by the people," says Bina Pokhrel, a researcher with the University of Hydelberg. "There are ample evidences to show that the problem is much more acute than what officials say."

Let's have a look at the worldwide scenario. According to UNAIDS and World Health Organization (WHO), the number of adults and children estimated to believing with HIV/AIDS by the end of 1999 is 33.6 million worldwide. Of them, six million live in South and South East Asia. An estimated 16.3 million people may have died of the dreaded disease since the advent of the disease till the end of this year. Of them, 1.1 million were from this part of the world. An estimated 2.6 million people are estimated to have succumbed to AIDS this year alone. Worse, every year nearly 5.6 million people get infected with HIV virus.

Sharing common, open borders with India on three sides, Nepal can't have a good nights sleep as far as HIV/AIDS is concerned. In 1998, India's National AIDS Control Organization (NACO) estimated there were more than four million HIV-infected people in India (about 1 percent of the adult population). By early in the next century, India will have the highest number of AIDS cases in the world, said the Organization. Even if HIV infection reaches the 'low' level of 5 percent seen in many other countries, more than 37 million Indian would be HIV infected by early next century.

Thousands of Nepalese go to Indian cities in search of jobs every year. Away from home for several years, most of them visit infamous Indian brothels in mega-cities like Mumbai, Calcutta and New Delhi regularly.

To their delight, they can choose between commercial sex workers from Nepal or different states of India. When they wake up to the reality that they have fallen victim to the disease which doesn't have any cure as yet, it is too late.

It is estimated that nearly 200,000 Nepalese girls and women are serving as sex workers in brothels in different Indian cities. Nearly 5,000 girls are trafficked from Nepal to India every year. And, the trade continued unabated. "The trade will not come to an end as long as there is demand for fair-skin Nepalese girls in Indian brothels," says Mrs. Anuradha Koirala, President of Maiti Nepal, who provides shelter to Mumbai-returned Nepalese girls, some of them HIV-positive. "There is no political commitment among our leaders to end this heinous crime."

Upon their return, Nepalese workers as well as Nepalese trafficked girls carry the dreaded virus back home with them. Even far-flung areas of the country are suffering from the problem. According to the annual report published by the UNDP-supported Participatory Planning and Management of HIV/AIDS (PPMHA) project last year,   Kashi Ram Sharma, who runs a pharmacy-cum-clinic at Saphe Bagar in far-western district of Achham, attends nearly 50 persons every day seeking advice/treatment for Sexually Transmitted Diseases (STDs) of which majority are women. "Gonorrhea and Syphilis are the two most common STD cases in this area," said Sharma. "Almost all the cases are chronic and are reported only at the secondary stage of the disease."

A retired Senior Auxiliary Health Worker, Sharma has been treating housewives infected from STDs obviously transferred by their husbands who work in Mumbai. "Despite our advice, they don't bring their partners and therefore, most of the STD cases remain untreated and reinfection occurs all the time, "recalls Sharma. "Breaking the cycle is very difficult. This all indicates a very grave situation for HIV/AIDS infection and spread in the area."

"The important factors that contribute substantially in the spread of the epidemic are spread of drug use, particularly through intravenous injection, migration and commercial sex workers. When people are away from their family and society, chances of their high-risk behavior increases," says Mahesh Sharma, national program manager of  PPMHA project, which runs HIV awareness and prevention programs in eight districts. "HIV/AIDS is not a priority issue for many. Therefore, the challenge is to raise awareness at all levels and advocate at a higher policy level so that proper attention is received and appropriate mechanism is developed in a multisectoral way."

It was only last year that the Nepalese government approved the National Strategic Plan for AIDS and STD Prevention (1997-2001), developed jointly by the National Center for AIDS and STD Control (NCASC) with technical assistance from UNDP and UNAIDS. Based on National AIDS policy, the strategic Plan emphasizes on multisectoral activities and close collaboration between NGOs, private sector and other governmental sectors in the joint effort to prevent HIV/AIDS. The plan also calls for creating an enabling environment for prevention efforts and care for those infected and affected by HIV/AIDS.

Experts, however, say that the government programs have not only failed to assess the magnitude of the problem, they are quite inadequate to cope with it. "While HIV/AIDS problem is moving fast with the speed of a motor car, government programs are moving with a speed of bull-cart," says Dr. V. L. Gurubacharya, a senior medical doctor working in the areas of STD and HIV/AIDS control. (See: Box)

The sense of urgency should come from the fact that the disease is spreading fast among the younger population. According to official statistics, about 90 percent of the total reported AIDS cases occur in the sexually active and economically productive 15-44 age group. "As the people of this age group are inquisitive and try to test new ideas and concepts, they are very much prone to HIV infection," said Dr. Vimala Arjyal, deputy director at the NCASC. "As such, we are focusing our programs on this segment of the population." (See:Box)

According to studies, high risk behavior groups like sex workers, transport workers, migrant workers, Police and Army who live outside their houses most of the time are more prone to HIV-infection.

"It is the youths who become migrated looking for jobs. Similarly, majority of the sex workers is also young. So, there is a need to educate them about risk behaviors and change sexual practices," said Bina Pokhrel. "Change in their behavior means they are safe from this disease. By saving our youths, we will be saving our future generation."

Unfortunately, this is not the case. As habits like drug use, particularly in the form of intra-venous injection, is growing among the youth population, increasing number of HIV-infection is being recorded among them. "Up to 50 percent of the drug users in some Nepalese towns have been identified as carrying HIV virus," says Dr. Gurubacharya. According to estimates, number of drug addicts in Nepal is nearly 50,000. This means that thousands of youths in the country are under great risk.

Global experience with HIV/AIDS and other sexually transmitted infections demonstrates that the most effective strategy to prevent an epidemic is to intervene quickly among the groups at high risk for contracting and spreading HIV. But identifying and reaching these groups is a major challenge in a country like Nepal.

"Most of the resources being spent in the name of HIV prevention is being wasted," says Rajiv Kafle, President of Prerana, a group supporting HIV/AIDS people. "People are dying of AIDS in the capital but no organization has come forward even to give them food and shelter."

 There is a need to provide low-cost treatment for people living with AIDS, home-based and community-based care and increasing the availability of cost-effective interventions for common infections like tuberculosis whose incidence increases among persons with AIDS, say experts.

The social and economic cost of HIV/AIDS could be enormous, say officials. "There will be the impact of HIV/AIDS in almost all sectors of development," said Dr. Arjyal. "As it is spreading among the  youths very fast we have to give top priority to control it."

For a country like Nepal, to respond effectively to infection trends and limit the costly social and economic impact of HIV and AIDS, its effort need to be accelerated, intensified, and expanded while the country remains at a low prevalence of HIV infection. With HIV prevalence doubling every one or two years in certain groups, there is a narrow window of opportunity over the next few years in which to prevent the HIV epidemic from becoming generalized and much harder to control.

The HIV is moving from urban to rural areas, say experts. But with taboo related to sexually transmitted diseases and lack of facilities to identify and treat them, it is difficult to assess the gravity of the situation in rural areas. Nepal could learn lessons from India toward fighting this disease.

According to a briefing paper published by the World Bank group recently, the Information, Education and Communication program of the National AIDS Control Project of India has made extensive use of traditional means of communication such as folk music, festivals, awareness campaigns, and elephant parades to highlight the risk of and how to prevent HIV/AIDS, especially among target groups. Special programs were developed to target youth through a school education program in 15 states, a pop music program, films and 700 Nehru Yuvak Kendra (Youth centers) across the country. The project also worked to increase the use of affordable, quality condoms through social marketing.

"Given the magnitude of problem, fighting AIDS requires strengthened partnerships between the government, NGOs, donors and the international health community," says the briefing paper.

Time is running out for Nepal. Unless there is political commitment and brad-based collaboration among different actors for the common cause of controlling this menace, unsuspecting women like Sharmila will continue to wake up one fine morning to the most haunted dream of their life-that is, HIV/AIDS.

‘HIV/AIDS Is Becoming More Prevalent Among Youths’

— DR V. L. GURUVACHARYA

A senior STD and AIDS specialist, Dr. V. L. GURUVACHARYA is working in the areas of STD and AIDS control and prevention for the last several years. He shares his views with SPOTLIGHT at his Central Clinic at New Road on the World AIDS Day (Dec. 1). Excerpts:

How serious is the problem of HIV/AIDS in Nepal?

The first cases of HIV was detected in Nepal a decade ago. Since then, the situation is becoming more complicated. Our programs are mainly focused at raising public awareness through mass media like Radio, TV and newspapers. To those areas where such media don't have access, people are still unaware about HIV/AIDS. Recently, this disease is becoming more prevalent among the youth population, particularly among those who take drugs through intravenous injections. In some cities, up to 50 percent of the drug users have been founding carrying HIV virus. Similarly, this disease has been found among commercial sex workers and their clients in different parts of the country. Men working away from homes have been found transfering the disease they have contracted from sex workers to their wives. In this way, this disease is also spreading among the general population of our society.

Why is it spreading so fast?

The main reason is that all of our programs are limited to raising public awareness only. We have been evaluating our programs on the basis of how many slots of advertisements we have shown through the media and how much money have been spent. We haven't done anything to intervene the spread of AIDS. There haven't been any effective programs to intervene among commercial sex workers, their clients, house wives and drug users.

What has been the main problem of our programs?

First of all, we have to assess the magnitude of the problem in Nepal. After that, we have to formulate national program of action. The role of government and NGOs in preventing the disease should also be well defined. There have been duplication of works and the programs are not effective. At the same time, the programs should be devised on the basis of geographical areas and should be evaluated every year.

Why is there more emphasis on prevention?

Till now, there hasn't been any medicine or vaccine developed to cure AIDS. So, the main theme is to stay away from this disease. We haven't been able to take targeted programs to the high risk groups. I don't know if there have been any evaluation of the HIV/AIDS control and prevention programs over the last five years.

How can people remain safe from HIV/AIDS?

The main thing is that sexual contacts should be made between faithful couples. In Nepal's case, such contacts should be made between husband and wife only. The threat of transmission of the disease through blood has reduced significantly as we have the provision of blood tests. Even now  several districts don't have blood testing facilities. Such facilities should be made available in those districts. In case sexual contacts takes place between the partners other than one's husband or wife, condoms must be used. It will help to prevent from the disease.

What could be the impact of spread of HIV/AIDS?

In Nepal, HIV/AIDS is spreading at a speed of motor car whereas government programs are moving at a speed of bullock-cart. If this pace  continues, our migrant workers will become more affected and they will transmit it to their wives. In this way, the country's agrarian economy will be affected. With the spread of AIDS among youths, they will become depressed and it will impart negative impact. If the situation remains same for the next years, our country will have to pay a heavy price for AIDS.

‘We Have Adopted A Multisectoral Approach’

— DR VIMALA ARJYAL

Deputy director at the National Center for AIDS and STD Control, DR. VIMALA ARJYAL spoke to SPOTLIGHT on the activities being carried out by the Center toward control and prevention of HIV/AIDS. Excerpts:

How serious is the problem of HIV/AIDS in Nepal?

On the basis of voluntary blood tests carried out at our surveillance centers, a total of 1376 people have been found infected by HIV. Of them, the number of people with full blown AIDS is 283. 139 people have already died of AIDS so far.

What is the trend of its spread over the last few years?

Four HIV positive cases were identified for the first time in Nepal in 1988. Since then it is going on increasing. In 1997, the number of AIDS cases went up. It is because nearly 50 percent of the Nepalese women returned from Indian brothels were found HIV positive. Earlier, the problem was more prevalent among sex workers only. Now it is increasing among the drug users.

What is the Center doing to combat with the problem?

The NCASC has formulated necessary policy, strategy and adopted multisectoral approach. It is not a matter related to health sector only. It could have impact on agriculture, forestry, tourism, education, on almost all sectors of development. So we are working in collaboration with all concerned agencies. As our efforts alone will not be sufficient, we have brought the NGOs under one umbrella. As per the principle of decentralization, we have been running door to door programs at the village level. Similarly, we are trying to expand blood sample collection and counseling services at the district level. We are also focusing on providing care and support to the people living with AIDS and integrating them with their family and community.

Why is the disease spreading fast among youths?

We have found that HIV/AIDS is more prevalent among the 14-29 age group. People are more inquisitive at this age. They want to test new ideas and experiment themselves. This year's World AIDS Day has also focused on this age group. Our programs are also focusing on this age group.