Cover Story (Spotlight Weekly)

HIV/AIDS

Adolescents Under Threat

With the large number of adolescents falling prey to the HIV/AIDS, the country is going to have to face an alarming situation where its youthful and energetic population will be vulnerable to killer disease. Although the country still has low prevalence rate of HIV, it is heading towards the situation of concentrated epidemic. If proper steps are not taken to intervene the spread of the disease, gravest of consequences are likely to hit the nation in the years ahead. As the time is running out, the country needs to start dealing with the crisis before it blows out of control

By KESHAB POUDEL

Young boys in Amlekhgunj (of Bara district), 200 kilometer south of Kathmandu, do not know what happens if they have physical relations with the commercial sex workers. Situated beside the east-west highway, many young boys and girls of this area are vulnerable to catching HIV because of presence of highway brothels.

Knowledge on STI (sexually transmitted infections) and HIV among young people in the area is relatively low. Majority of young boys in the area had girl friends and most of them engaged in pre-marital sex. Despite knowing the importance of condom in the protection against the STD/STI and HIV, the youths did not use them.

According to a summary report of the Impact Evaluation Report Combating HIV/AIDS:

Advocationg safe practice : Campaigning against AIDS

A Literacy and Economic Approach Project, youth and adolescents are highly vulnerable to the infection of HIV. Prepared by Dr. Giridhar Sharma Poudel, for Samjhauta Nepal, an NGO, the report highlights how vulnerable the young population is and how extensive is the threat of HIV/AIDS.

Not only the youths and adolescents from Bara district but from all other parts of the country are similarly vulnerable. Recently, Maiti Nepal, an NGO active in preventing and control of girl trafficking, rescued 10 young girls aged between 15-19 at Mugling, 100 kilometer west of capital Kathmandu. The girls were on their way to New Delhi, India where they would most likely have been sold off to brothels. Other nine girls could not be rescued because they were traveling in different bus. The girls were reported to have come from Sindhupalchowk district, 50 kilometers south-east of Kathmandu, which has been one of the major hotbeds of girl trafficking.

Had they not been rescued, these illiterate and naīve girls would have been sold off to brothels where they would have been compelled to engage in flesh trade; and they would have to return to their country carrying HIV infections. Studies have shown that more than 98 percent of the girls who return from Indian brothels are infected with the HIV and over 30 percent of commercial sex workers in Nepal are infected with the disease.

Although the mass media including Nepal Television and other private owned radio stations regularly broadcast messages cautioning young girls against falling prey to the wily traffickers as well as warn young people about the hazards of HIV/AIDS, they are yet to have a desired impact on the population living in adjoining districts of capital. It is anybody’s guess how the situation must be in remote parts of the country. It is estimated that more than 7,000 Nepalese young girls are trafficked to India every year.

Despite the attempts of media campaigns that target the adolescent youths, the situation is yet to change. As the number of vulnerable population including drug users and commercial sex workers increase in urban centers, more and more adolescent populations are at risk.

Maiti Nepal, which also works to rehabilitate the girls who return from Indian brothels, now has 46 girls and children infected with HIV/AIDS in its rehabilitation shelters.

Vulnerable Groups

With the revelation of more than 60 percent of Human Immunodeficiency Virus (HIV) infected populations reportedly from the age group below 30, Nepal's HIV/AIDS epidemic has sent an alarming message threatening country's future economic growth and development process. Alarmed by the new trends, officials and international donor communities have already initiated certain programs like increasing supply of condoms and awareness campaign through the media.

A HIV positive girl who returned from India : Victimized and

Under its Global Health Fund, World Health Organization (WHO) has recently agreed to provide substantial amount of money in the areas of HIV/AIDS prevention program.

From national newspapers to television channels and Radio stations and mobilizing the local non-governmental organizations, the authorities are targeting the adolescent and youth populations. But, the isolation and extreme poverty of general population provide a breeding ground for rapid spread of epidemic to the general population.

"Any delay in initiating policy action on HIV/AIDS will have a devastating impact on national economy, with adverse consequences in the region," warn experts. "National productivity will be the first casualty since HIV/AIDS largely affects people in the 15-49 age.”

"The high costs to the government in the form of lost services, lower national productivity and output, loss in skills and experience, depletion of workforce in specific sectors, increased demands on health and social sectors, and loss of human capital can push the country into a vicious circle of poverty," warns the UNDP's Report HIV/AIDS and Development in South Asia 2003.

According to national census 2001, the population below 24 age groups consists of more than 58 percent of the country's total population of 23 million. Infections of the HIV in this age group will affect country’s overall productivity.

Data regarding HIV/AIDS is very scarce. However, available data indicate that around 0.5 percent of the general population is HIV positive As of June 2003, National Center for AIDS and STD Control reported 2942 HIV infections and 167 deaths by AIDS. According to Ministry of Health 59 new cases of HIV were reported in June, with 8 deaths by AIDS. Among the total infected population, 1,515 were below the age of 29 and 250 below the age of 19. This result is based on 200,000 voluntary blood tests. The June's data indicate continuous infection among the population of young group. Out of 59 new cases in June, 34 were below 30 years of age.

"The trend is very much alarming and there are needs to take immediate steps to prevent the situation," said Dr. Ramhari Aryal, a demographer and joint secretary at National Planning Commission (NPC). "Any delay in initiating policy action on HIV/AIDS will have lasting impact on the national economy with adverse consequences for human development in the country."

The first HIV case in Nepal was diagnosed in 1988. In 1991, there were only 24 reported cases of HIV infections and the cases in Nepal were comparatively lower than all other countries in the region. The situation has changed today. Had the policy makers taken the case seriously, the situation would not have been as worse as today.

UNAIDS/WHO estimates there are 60,016 cases of HIV/AIDS and 2,958 deaths due to HIV/AIDS in Nepal. Likewise, the United Nations Development Program (UNDP), the Regional Human Development Report HIV/AIDS and Development in South Asia 2003 estimates that the HIV prevalence rate among adults is higher in Nepal. It stands at 0.5 percent. Nepal has the second highest prevalence after India where 1,500 children below 14 years were infected.

In its recently released report on the State of the Children by CWIN, large numbers of children are under the potential threat of infection of HIV/AIDS. They have recorded deaths of 10 children below the age of 14 by this disease.

As most of the infected populations are marginalized people, the impact of HIV/AIDS at their household levels will have devastating consequences for their family members. "Members of the marginalized population will have to face greater risk and it will affect the poverty reduction process," said Aryal, a demographer and joint secretary at National Planning Commission. "We have already formulated a long term strategy to control the HIV infections among the young population giving them all available resources to prevent it."

Others, too, argue that the adolescents are under greater risk of HIV. Along with infection of the HIV/AIDS through sexual contact with commercial sex workers and Intravenous Drug Users, the change of sexual behavior is also making youths more vulnerable.

"We have been running programs targeting youth and adolescent population. Our experiences have shown there is a need to launch many other programs focusing on adolescents and youth," said Nirmal Kumar Bista, executive director of Family Planning Association of Nepal (FPAN). FPAN works with communities, adolescents and youth and local leaders, who are committed to sustaining these centers, which are popular among the youth.

Experts argue that Nepal is reaching a very critical stage of HIV/AIDS epidemic. "If the HIV continues to infect younger people of productive age groups, it will have direct impact on infant mortality rate and overall life expectancy," said Dr. Bhanu Niraula, assistant representative of the United Nations Population Fund (UNFPA). "We are supplying condoms to prevent HIV infection amongst young people through expanding access to information, life skills based education, youth friendly health services and ensure protection, care and support for orphans and children in families made vulnerable by HIV/AIDS."

Published by UNAIDS and National Center for AIDS and STD Control, HIV/AIDS/STW and National Response in Nepal 2003, the country profile, reveals that Nepalese teenagers are highly aware of the HIV risk, but this awareness does not necessarily translate into safer sexual behavior. According to its report based on targeted audience, although an overwhelming majority of 92 percent of teenagers had heard of HIV/AIDS, only 74 percent teenagers knew that they should use condoms for safe sex and only two thirds say they should not have sex with commercial sex workers. The study also shows that almost 20 percent of teenagers considered premarital sex as proper.

"The Ministry of Health has been taking initiatives targeting young," said Dr. Beni Bahadur Karki, spokesman of Ministry. "We are stressing for prevention activities increasing supply of condoms and early treatment of STD and STI."

A 1999 Family Health International (FHI), an American International Non-Governmental Organization, study looking at the sexual behavior of 800 students, truck drivers, and laborers in Nepal showed that 71.5 percent of them have had their first sexual intercourse before they reached the age of 19; about 80 percent of them have had sex with their girl friends and female partner and 3.6 percent reported they had visited commercial sex workers.

Maiti Nepal girls guarding a border post : strict vigil

The girl children of age group of 13-20 from the marginalized communities are often driven into the sex industry inside the country and across the border, usually because it is the only means of generating income for their families. According to estimates made by the different non-governmental agencies there are 25,000 commercial sex workers and 20 percent of them are younger than 16 years. Higher mobility of people across the porous border with India and an estimated 5,000 to 7,000 girls trafficked annually for flesh trade also increases the threat level.

Injecting drug use is fueling the rapid spread of HIV in Nepal. The HIV prevalence shot from 2.2 percent couple of years ago to over 60 percent by 2002 among injecting drug users (IDUs) who numbered around 30,000 as of 2002. Interestingly, more than 60,000 drug users, including non-injecting drug users, are in the 16-25 age groups.

New epidemiological data suggests that HIV may be increasing more rapidly than expected in the sub-groups. "In fact it is becoming likely that Nepal will enter the state of a "concentrated epidemic", i.e. the HIV/AIDS prevalence consistently exceeds 5 percent in one or more sub-groups. These include Injecting Drug Users (IDUs) nationwide, female sex workers (FSWs) in urban areas and returning sex workers from India," said a demographer.

UNAIDS/WHO estimates that AIDS prevalence was 2 percent or below among female sex workers (FSWs) and IDUs in the mid 1990s. But it has now reached 68 percent among IDUs in Kathmandu and is approaching 20 percent among FSWs and is over 70 percent among FSWs who also report being IDUs. The dominant route of transmission is heterosexual through unprotected sex and sharing of syringes among IDU. The most vulnerable groups are sex workers and their clients.

According to reports, by the end of the first decade of the 21st century, the HIV may have become the number one killer of Nepalis in the age 15-49," said Professor Bal Kumar K.C, who teaches demography at Tribhuwan University, country's oldest university. "If we do not take immediate steps, the epidemic will affect our whole development process."

"The Ministry of Health has been taking initiatives to intervene in the process," said Dr. Beni Bahadur Karki, spokesman of Ministry. “We have prepared a strategy for period of 5 years (2002-2006). It takes into account various issues to be dealt with and identifies various components for the containment of HIV."

IDUs, female sex workers and girl trafficking remain a major factor of transmission of HIV to younger generation of population.

Supported by the World Bank and Pact Nepal, a recent study conducted by Samjhauta Nepal after its completion of project Combating HIV/AIDS: A literacy and Economic Approach in few villages in Bara district revealed that the behavioral change of adolescent and youths are also responsible for increasing risk.

The report reveals that more and more youth and adolescents are involved in sexual activities without using condom. The study also reveals that there is a growing tendency to have friendship and affair between the school going boys and girls.

"Our project increased an understanding of the threat of HIV/AIDS in daily lives of women; the social dynamics in stemming its spread and demystifying myths surrounding AIDS; educating women on how they can protect themselves, their parents, their children (especially daughters) from AIDS despite the stigma associated with such discussions; educating to negotiate safe sex with their husbands in spite of the constraints of Nepali women's status," said Usha Jha, chief executive officer of Samjhauta Nepal. "Our projects have also taught importance of condom to prevent the spread of HIV."

For many years, the government policy ignored the importance of youths and adolescents in preventing the spread of HIV. The government version was that the HIV transmission problem was mostly the result of blood transfusion in Nepal. Even among the blood donors, the prevalence has gone up tremendously from 0.2 percent in 1991 to almost 4 percent in 2002.

"HIV is certain to have an immense impact on the socio-cultural and economic life for a country like Nepal. As an agrarian country, where four fifth of adults are engaged in agriculture it is likely to lose many farmers in their productive years along with loss of production in factories, loss of economy in other various sectors and ultimately the GDP. As the young population declines, so will the production and annual income of the family," said Pancha Kumar Manandhar, vice president of Nepal Population Association.

By celebrating the World Population Day by targeting the adolescents and youth population, the vulnerability of adolescent population was seriously taken into consideration. But the question remains how will the government respond to tackle the issue. According to a survey conducted by Aama Milan Kendra's Adolescent Girls' Program a year ago, it was revealed that there is a very low rate of literacy among the girls between 10-19 years and average age at their marriage. Average age at the marriage was found 16.6 years and there were 16.2 percent teenage pregnancies. Likewise, the study estimated there are 5000 girls below the 16 years among the commercial sex workers in Nepal - which consists of 20 percent of total number of sex workers.

Studies have already shown that by the end of the first decade of the 21st century, the HIV will have become the number one killer of Nepalis in the age 15-49 and more number of younger populations will have HIV. Unless effective interventions are carried out, this spread will have cascading effect on all sectors of development and economy of the country.