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COVER STORY |
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COVER STORY |
HIV/AIDS As the HIV virus has
already deeply penetrated into the concentrated populations like Injecting Drug Users
(IDUs) and commercial sex workers, the recently formed National Association of People
Living with HIV/AIDS in Nepal (NAP+N) provides a new hope to prevent it from spreading
outside to the general population. Studies have predicted that HIV/AIDS is going to be a
major killer among the age group of 14-49 by 2005 with average deaths of 40 a day in the
country. It, therefore, requires greater involvement of different stakeholders in a
campaign to drive the disease away. At a time when the country is engulfed in the Maoist
conflict, how the government will accommodate different stakeholders in this campaign and
how successful it will be to contain the spread of HIV/AIDS remains to be seen By KESHAB POUDEL When Jaljala Khatri, 25, (not real name) a
cabin attendant at a local cabin restaurant in Balkumari, Lalitpur, watched the television
interview of Rajib Kafle, she felt concerned about herself. “Whenever I go with the
boys, a message delivered by a HIV positive Saran Chettri in Nepal Television, haunts my
mind cautioning possible infection of HIV,” said Khatri, a resident of Ramechhap
district. As her job demands, she is compelled to
entertain clients. In most of the cases, Khatri and her other colleagues have to spend
night with their male clients.
“If all our clients similarly
disclose their disease, we would not be infected,” said Khatri who is among many
girls working in the cabin restaurants in the valley who are aware about the HIV, STI and
STD (Sexually Transmitted Infections and Diseases). As such, Khatri is always
worried if the disease will also infect her one day. There are between 10,000-15,000 girls aged
between 14-32 currently working in cabin restaurants; dance restaurants and massage
parlors in the valley. According to police report, there are about 500 such restaurants in
the valley. Though they are not employed as sex workers, these girls sell sex to make
additional money, knowingly and unknowingly, standing as a medium of transmission of
deadly HIV virus and STI/STD to the general population. “I came here to work as a cabin
attendant. Two months after my arrival, my owner forced me to entertain the guest,”
said Khatri. “Since my salary is not adequate to live in the city, I sell my body and
get additional money. I always request my clients to use the condoms but only few men
accept my suggestions,” said Khatri, who was taught about the importance of safe sex
by some NGO workers. Thanks to the programs launched by
different non-governmental organizations including People Living With HIV/AIDS (PLWHA),
many girls working in cabin restaurants are now aware about the disease. Although condom is encouraged among such
girls, carrying condom is risky too. “If police recovers condom from our purse during
their raid, we will be taken into custody as a prostitute,” said Maili Bhujel, (not
real name) 25, a mother of two children who has to entertain young boys in the cabin
restaurants. Like Khatri, Bhujel is also afraid of the possible infection of HIV. Working as waitresses at cabin and dance
restaurants, discos and as masseurs at massage parlors, the sex works are vulnerable and
could be spreading HIV virus to the large segment of population. Some sex worker who work
in garment factories and carpet factories, do business in the street.
Rukmani Thapa, (not real name) 28,
works at a cabin restaurant in Swayambhu. Thapa, a resident of Gulmi, came to Kathmandu
two years ago with her relatives hoping to find a better job but she landed at a cabin
restaurant. Thapa, who is treated for STI, was gang raped twice by a group of taxi
drivers. “I don’t want to go outside the restaurant since I had bitter
experience in the past,” said Thapa who is considering going for voluntary blood
test. “I have seen the people with HIV walking and talking with others, I will also
go for blood test to see whether I am already infected by the HIV.” Since prostitution is illegal, it is crime
to work as commercial sex workers. In the last few years, some non-governmental
organizations have penetrated inside the world of commercial sex workers and are
encouraging them to change their behavior. Voluntary disclosures will encourage many other
sex workers like Thapa to go for blood tests and they will also begin to ask their clients
to practice safe sex. A survey conducted by the Family Health
International in Kathmandu in 2000 revealed that 17.3 percent of sex workers were
HIV-positive up form 2.7 percent in 1996. It is estimated that as many as 70 percent of
sex workers returning from India are HIV positive. Although there are no national data on
prevalence among sex workers, it is estimated that the proportion is very high. IDUs Story The story of Aanam Shrestha, 19, is
different. Being an Injecting Drug User (IDU), Shrestha shares syringes with his friends.
“We are often requested by workers of non-governmental organization not to share
needles but we don’t have other options. Since drug use in any form is illegal, we
share syringes among a small group of close friends to protect ourselves from arrest by
police,” he said. “We are high risk groups for HIV infections but it is not easy
for us to give up our habit. If syringes are easily available, no body wants to share it
with others.” According to a study conducted by the
government, there are an estimated 30,000 people in Nepal who are IDUs and nearly 45
percent of them are either married or have a partner, many of them have higher education,
and they come from a wide range of caste and ethnicity.
Theme Group in Nepal reveals that
through sharing of needles and syringes, HIV has spread rapidly in this community,
reaching prevalence rates of 68 percent in the Kathmandu Valley, and between 20 and 45
percent nationwide. UNAIDS Prediction World Health Organization and UNAIDS
estimate that Nepal has 61,000 people living with HIV/AIDS, many of them belonging to
vulnerable groups like sex workers, injecting drug users, labor migrants and their
families, the epidemic is firmly rooted in Nepal and spreading at an alarming rate. The studies have already predicted that on
average 40 people will die every day by AIDS in 2005 and most of these people will be
young. National HIV/AIDS Strategy (2002-2006) predicts that there is high potential
for a generalized epidemic in Nepal. In the absence of effective interventions,
even a “low to moderate growth scenario” would make AIDS the leading cause of
death in the 15-49 year old population over the coming years. According to report, for
Nepal this would mean that around 100,000 -200,000 young adults will become infected and
the overall 10,000- 15,000 annual AIDS cases and deaths may be expected. Since the problem has already reached an
alarming level, the response of the government is too little and too little to counter it.
“The situation will be alarming by 2005 when the country will see the dead bodies of
about 40 people every day caused by AIDS,” said Rajib Kafle, the president of the
National Association of People Living with HIV/AIDS in Nepal (NAP+N) at a press
conference. The government, too, accepts that HIV is
spreading. ”The government is sincerely committed to prevent the spread of HIV in the
general populations. I cannot claim that we have adequate programs but our policies and
programs are directed to prevent the HIV,” said Dr. Ram Prasad Shrestha, director of
National Center for AIDS and STD Control. “Our strategy now is to provide cure to
those who are infected by HIV and to prevent further infection.” PLWHA’s Difficulties Although Khatri’s wish to see many
people disclosing their status has valid grounds, majority of people infected with HIV
have to face many social discrimination and stigma. “The trend is gradually changing
in society but it will take many more years for people with HIV/AIDS to receive
non-discriminatory treatment,” said Sunil Panta, president of the Blue Diamond
Society, an organization that advocates for rights of homosexuals. “I think that the
present number of HIV/AIDS patients in Nepal is accurate. It is underestimated, there are
many more men and women living without knowing that they are infected.”
Life of People Living With HIV/AIDS
(PLWHA) is more vulnerable and their voices are ignored even as they are neglected at the
policy level. According to definition, the term PLWHA consists of individuals living with
the symptoms of AIDS to HIV-negative partners, family members and close friends of
HIV-positive persons. In rural parts of the country, they often
face discrimination and harassment thanks to the stigma. Women, whose husband die of AIDS,
have to face all kinds of discrimination. Although these women are innocent, they are
blamed for the infections. Geeta Basyal, a woman living with HIV, has
a painful story to tell about discrimination and exclusion from family member. Hailing
from village, Basyal, a mother of a girl, was infected by her husband. “It is terrible and I cannot explain
in words the situation of women in rural parts of the country. In urban areas, it is
comparatively better but in villages, often, women with HIV are treated as pariahs. Thanks
to stigma about the disease, no one wants to talk to us or our children,” said
Basyal. “The government has done nothing for us and our problems are ignored.” Treatment and Cure Although the treatment facilities are
available in other parts of the world, Antiretroviral therapy, treatment of opportunistic
infections, and community based care and support services are virtually non-existent in
Nepal. Barring few exceptions, PLWHA have no access to services and are often refused
treatment by medical doctors and medical staffs. To celebrate the World AIDS Day, the
government has announced it will freely provide Anti Retroviral therapy at some hospitals
and the Maternity Hospital has also announced the opening up of treatment to prevent
mothers-to-child infections. The Hospital has already successfully used to this treatment
on two pregnant women with HIV. “The United Nations System in Nepal
shares the concerns of PLWHA as regards access to treatment, care and support, and urges
the concerned government institutions to develop a respective policy,” said Matthew
Kahane, UN Resident Coordinator, UNDP. “With cheaper drugs now available
globally, Nepal would have a golden opportunity to start services for PLWHA in planned and
systematic way. What it would require is training of medical staff, upgrading of
laboratory services, and finally provision of medicines- not only in Kathmandu but also at
the decentralized level. Precondition for care and support services is to break the stigma
and discrimination, and to provide voluntary counseling and testing service, ” said a
joint press release issued by The UN Theme Group Nepal and NAP+N. Despite strong commitments from government
and donors, the cure and treatment services are yet to expand in the country. The Achham
district, 500 miles far west of Kathmandu, is regarded as one of the most HIV/AIDS
affected districts in the country. Along with remoteness, the raging Maoist conflict has
prevented authorities from providing basic services in the district. “When talking
about the treatment cure and support of PLWHA, one must not forget the people living in
the districts like Achham where the discrimination is rampant,” said Bina Pokharel,
who works with Save the Children UK. Three Crusaders Despite greater demands from public and
government officials, the voluntary disclosure about the disease is not an easy one. Since
the last many years, only three people with HIV positive have publicly declared their
status. The challenges and difficulties to live
life after publicly declaring as a PLWHA is an uphill task. Despite encouragement, only
three persons - Rajib Kafle, Saran Chettri and Lama – have declared their status out
of 61,000 infected people. “You have to face many discriminations to live in rural
society after publicly disclosing the status,” said Basyal. In Nepal, like in most other countries in
Asia, the stigma of HIV creates barriers that block PLWHA and others who are vulnerable to
infection from coming forward to access the services and education that they require.
PLWHA have limited access to care and support services, treatment and opportunities to
create sustainable livelihood and to participate in decision-making regarding the HIV
response. Maiti Nepal, a pioneer organization
fighting against the girl trafficking, employs some girls with HIV positive and takes
their service to rescue other girls from being trafficked to India. While public
disclosure is not easy for these girls, they are actively participating in the efforts. USAID’s Support In collaboration with the National Center
for AIDS and STD Control, USAID supports POLICY project in the promotion of the greater
involvement of people living with HIV/AIDS (GIPA) principles in Nepal In a recent study conducted by the USAID on
the greater involvement of PLWHA, it was revealed that there was a broad consensus among
those interviewed that the involvement of PLWHA in the response to HIV/AIDS in Nepal is
important and should be incorporated in national program and policy activities. “Stigma and discrimination is the
cornerstone of the whole fight against HIV/AIDS, Until we fight this stigma and
discrimination nothing is really going to change here. Once you have stigma and
discrimination HIV/AIDS is definitely going to be socially submerged. Once it is totally
submerged then they are not going to come out. If they are not going to come out then how
are we going to plan the responses? So it will be difficult for us to give services and
monitor them. If it is totally submerged then people will never talk about HIV/AIDS. If
they do not talk about it they would not know how to protect themselves. They would not
discuss and know the precautions and tools to protect themselves. Another important things
is if PLWHA don’t come out then how are we going to protect their rights, which is
the basic principle of GIPA,” writes Bandana Rana, president of Sancharika Samuha and
co-researcher. According to the study all the respondents
interviewed stated that stigma and discrimination were the major disincentives to the
promotion of GIPA and fundamental barrier to greater PLWHA involvement. “There are very few PLWHAs that have
disclosed their status and almost all of them come from an IDU background. In Nepal there
are many migrants particularly in the mid west and far western region who come back home
with HIV and infect their wives and subsequently their children. The voices of these
people are mainly silent,” writes Bandana Rana. “The majority of the PLWHA who
have revealed their status are from low socio-economic strata with only basic
education.” Responding to researchers, PLWHA agree that
most of the PLWHA are illiterate –only 3 or 4 have come forward and they don’t
have all the knowledge. The GIPA principal endorsed in 1990 Paris
declaration is yet to be fully implemented in Nepal. The most well-known and widely used
expression of the GIPA principal is the process of public disclosure. In a sentence, GIPA
is a disclosure of identity of the person with HIV. Despite endorsement of GIPA as a best way
to improving the HIV/AIDS policies and programs, reducing stigma and discrimination,
protecting human rights, providing better access to treatments and appropriate medical
care, it is yet to have impact on Nepal. Conducted jointly by the National Center
for AIDS and STD Control and USAID/ Policy Project, the preliminary findings from the
study on the greater involvement of people with HIV/AIDS in Nepal reveal that the GIPA was
a difficult challenge for Nepal. The major barrier was stigma and discrimination, which
discouraged PLWHAs from coming forward. Although the research does not include the voices
outside the valley, it helps to understand tentative position of HIV. Jaljala’s dream cannot be fulfilled
right now but she will definitely see changes in the behavior of persons with HIV. Unlike
the situation of couple of years ago, society has gradually started to accommodate people
with HIV in mainstream, at least in urban areas. How the shift in the attitudes in society
will support the HIV prevention remains to be seen. Sex workers like Jaljala will have to
wait until then to heave a sigh of relief. “While The Males Commit Mistakes, Females Face Discrimination” — Geeta Basyal GEETA BASYAL, a woman with
HIV, hails from the western parts of the country. A mother of a girl child, Basyal was
infected by her husband. Facing discriminations in society, Basyal has been struggling for
survival for the last five years. Basyal spoke on various issues regarding the problems of
HIV/AIDS patients. Excerpts: As a woman with HIV/AIDS how do you
see the situation? Oh! It is terrible and I cannot explain in
the words the situation of women in rural parts of the country. In urban areas, it is
comparatively better. In Gorkha district, a woman called Minu Thapa, who has been living
with HIV, has been even stopped from sending her children to schools. Often, women with
HIV are treated as pariahs. Thanks to the stigma about the disease, no one wants to talk
to us or our children. How do you see the government
efforts in the HIV/AIDS prevention and control? The government has been doing nothing for
us. The problems of HIV/AIDS patients have been ignored as if they are not problems at
all. Unless the government makes strong commitment, HIV/AIDS epidemic will not be
controlled. What about your family
members? I have a daughter and she is supported by
one of the non-governmental organizations for her studies. Thanks to the support of the
Center for Children of parents with HIV, my daughter is getting school education. I
don’t know what to do in future. Actually, I want to make my daughter a doctor but
who will pay the cost for that? Being a person with HIV, no body will support us. Don’t you benefit from
disclosing your disease? In urban areas, the situation is
definitely better and we don’t have to face discrimination but the situation is
completely different in rural areas where your life will be completely different once you
openly declare that you are infected with HIV. Aren’t there rehabilitation
centers for women with HIV? There are some rehabilitation centers for
women with HIV. Merely by living in such rehabilitation centers will not solve the
discrimination faced in the rural areas. The rehabilitation centers offer us food and
shelter. Some centers even offer the treatment but it is just for few HIV patients. We are
considering to establish an organization to promote the cause of Women with HIV Are you receiving retroviral
therapy? Although the price has come down, it is
still too expensive for me to buy the retroviral. Since it is expensive, I cannot buy on
my own. So what do you want then? Our real issues are ignored since we
don’t want to confine our activities in rehabilitation centers as patients. We want
move ahead to generate the awareness in society and serve others. How is the financial position of
persons like you? We don’t have a penny. In most cases,
women are kicked out from their family once family members know that their
daughter-in-laws are infected by HIV. In most of the cases, women are infected by their
husband. In many cases when the HIV infects husband and wife both, husbands receive more
care than wife. While the males commit the mistakes, females face the discrimination. How do doctors and others treat
patients with HIV? The situation is definitely improving in
the hospitals but there is still discrimination in treating the patients with HIV. “If We Do Not Take This Issue Seriously Now, It Will Turn From Bad To Worse” — Dr. Ram Prasad Shrestha
Dr. RAM PRASAD
SHRESTHA, director at the National Center for AIDS and STD Control, is a well-known
medical practitioner. Although Dr. Shrestha is professionally a surgeon, he is well-known
for his knowledge on managerial experience. Shrestha spoke about the role of the center in
the prevention and control of HIV/AIDS. Dr. Shrestha spoke to SPOTLIGHT on these issues.
Excerpts: How do you see the present status
of HIV/AIDS in Nepal? HIV/AIDS is increasing steadily as it is
estimated that there are more than 60,000 patients living with HIV/AIDS at present.
Interestingly, our health centers have registered just over 3,000 cases related to
HIV/AIDS. Since the HIV/AIDS is just in the concentrated epidemic stage, it is confined to
certain groups like sex workers and IDUs. So this is also an opportunity to control the
epidemic. If we cannot contain it in these two groups, it will spread to the general
population. Why is there such a huge gap? We don’t know the reasons behind it.
It may be the gap of information or the poor process of detection and surveillance or the
estimated figure may be highly exaggerated. If there are certain deficits in the process
of accumulation of information and detection, we must make efforts to improve our
surveillance and detection method. Is the situation not alarming? The figures portray the real situation. If
we do not take this issue seriously now, it will turn from bad to worse or from
concentrated epidemic to general epidemic. Studies have already shown that we have to take
certain drastic steps to prevent the spread of disease. If the situation remains
unchanged, AIDS is going to be the leading cause of death among the 15-49 year old
population in the coming years. The people with HIV/AIDS and other
non-governmental organizations blame the government for not taking the issue seriously.
How do you look at it? The government is very much committed to
control and prevent HIV/AIDS and to provide other services to the patients with HIV. The
government has placed the HIV as a priority area. We are talking with different
stakeholders about the problems of HIV/AIDS. Certainly, there are some weaknesses and
lapses in our program but it is not a total failure. How do you see the participation of
stakeholders? Frankly speaking, it is impossible to bring
much change without the participation of stakeholders. We are encouraging non-governmental
organizations and people living with HIV in our programs. To encourage greater involvement
of the people with HIV/AIDS, we are introducing the GIPA principal, the process of public
disclosure. We have to thank development partners for their continued support for the
HIV/AIDS prevention programs. What is the present scenario of
participation of people with HIV in your programs? Since the government is also working with
different networks of people living with HIV/AIDS and other community based organizations,
we have seen definite improvement in this area. Gradually, there will be greater
involvement of such people in the HIV/AIDS prevention programs. How do you evaluate the present
policy? You can see a number of important changes
since the development of the Strategic Plan. Nepal’s National HIV/AIDS Strategy
2002-2006 has been designed to guide the expanded response to the HIV/AIDS epidemic in
Nepal. The document has prioritized areas where immediate attention needs to be given and
defined strategies that will be most effective in the socio-cultural context of Nepal. We
have been given the responsibility to identify strategies that will be most effective in
the socio-cultural context of Nepal. We are giving priority to the prevention of HIV among
those groups most at risk of getting infected. What programs are there for
surveillance and research? We have also identified surveillance and
research as a priority. We are giving focus in the strategy to the treatment, care and
support of people infected and affected by HIV/AIDS. Our experience has shown that there
is reduction in discrimination towards infected and affected people. We are also making
efforts to take good care of persons infected and affected by the epidemic. |
Send your feedback to the
editor: spotligh@mos.com.np |
