July 29 2005

With the number of HIV\AIDS patient increasing, the country’s economic sector is gradually feeling its consequences. Till now, HIV\AIDS used to be taken purely as a medical problem and the governments’ policies largely focused their attention on medical cure and treatment. Of late, however, the disease as much dreaded by economists as by health workers. As most of the people living with HIV are younger in age, the disease robs the nation of young workforce resulting in economic slowdown and various other cascading effects. Therefore, the time has now come to work out a plan to prevent long term economic consequences of the disease

By KESHAB POUDEL

Rajan Gurung, (name changed), 29, a resident of Pokhara, 200 kilometers west of capital, was infected by HIV/AIDS a few years ago. He needs to spend more than Rs.2000 (roughly around US$ 30) a month on medicines. Father of two children, Gurung, who caught the disease while working as a security guard in Nagpur India , is faced with a sad dilemma - whether to spend his paltry resources on education of children or his own medical treatment. Adding to his woes, his wife Chandra Maya deserted him last year upon knowing of the disease, which still carries social stigma.

“I have to send my two children to schools and take care of my family of five including mother and father. I cannot afford such a huge sum of money to buy medicines. If I do not use medicines, then I cannot work hard,” said Gurung, who is now working as a security guard in star hotel in Pokhara – a popular tourist resort. Gurung e arns about Rs. 4,000 (around US$ 60) a month as salary. He does not have other income sources.

 Gurung is not an only adult infected by HIV/AIDS facing such consequences. There are thousands of people like Gurung – whose monthly income is very low and has to take care of their family - facing similar dilemma.

Gurung needs medicines to weaken the HIV but spending his income to buy medicine will affect education of his children and hand-to-mouth problems of family. “I am really in a dilemma what I need to do,” said Gurung.

Nirmal Neupane, (name changed), 24, a resident of Chautara, 50 miles east of capital, too, is facing similar problems. The only son in his family, Neupane has to work to take care of his four family members including his small sister. Neupane, an undergraduate was infected while studying in the capital. “My only crime was that I visited a dance restaurant (places where pimps and prostitutes, too, hang out) a few years ago. I cannot disclose about the disease to my family and I don’t have money to buy medicine,” said Neupane. “I used to work for eight hours a day till few years ago, but I feel weak and tired now,” said Neupane, who is working as a shopkeeper. “I earn salary of  Rs 3,500 and have to send some money for my family.”
Many studies have already been conducted to find out about various aspects and consequences of HIV\AIDS including the lives of commercial sex workers, IDUs (Intravenous Drug Users) and so on but only a few efforts have been made to assess the economic impact of the disease.

“HIV/AIDS is a different form of disease since it affects young adults. Economic impact of this disease will not be just on this generation, but the next one, too, whose education will suffer. Economic costs can be huge, and felt many years from now,” said Dr. Shanta Devarajan, chief economist, office of the vice president, South Asia Region, the World Bank, addressing a talk program on The Economic Costs of AIDS.
With the number of HIV\AIDS cases rising, it will affect the labor supply reducing Gross Domestic Product. It will also affect public finances. Increased health expenditure results in reducing public investment and reduces GDP growth.

“AIDS kills young adults and reduces incentives meant to invest in children’s education,” said Dr. Devarajan. “Previous estimates of impact of AIDS may have seriously underestimated the long-run impact.”

In the last few years the number of HIV positive patients have increased tremendously. After the intensification of insurgency, a large number of people moved from villages to the urban centers making the situation more critical.

“It is estimated that Nepal has 62,000 HIV positive persons but reported/registered HIV number till June 2005 was 5000. Deaths per year due to the disease is about 300-500. Orphans due to the AIDS is about 2500,” said Dr. Shyam Sunder Mishra, director of National Center for AIDS and STD Control. “Around 46 percent of the population affected by HIV\AIDS are in the age group of 20-29 years.”

Organized by the World Bank Nepal Country office recently, a one-day seminar on long-term impact of HIV\AIDS discussed many issues ranging from economic cost of HIV\AIDS epidemic to other matters. Senior health consultant at the World Bank, Dr. Tirtha Rana made her presentation on long term economic implications on Nepal .

According to the Human Development Report 2004, Nepal is among the economically poorest countries in the world. Nepal ’s social indicators remain well below the average for the South Asian region. Despite certain achievement in poverty reduction, more than 30 percent people still live below the poverty line with average income of less than a dollar a day.

Like Gurung, mobility among the people is historically higher. With the intensification of Maoist insurgency in the rural hinterlands, a large number of Nepalese have already migrated to different urban centers of Nepal and India . According to experts, each of these mobile groups and their respective families are vulnerable to HIV\AIDS. Estimates ranges from 1.5 to 2 million Nepali nationals, who work outside the country, 1 million are estimated to be in different parts of India alone. According to UNAIDS, the recent studies among labor migrants revealed that HIV sero-prevalence rates is between 2-10 percent for migrants returning from Mumbai , India .

Displaced from Humla district of northwestern Nepal , Sapana Shahi, 28, is now leaving in Kathmandu . Shahi is now working as a prostitute in the capital. “I have no option other than to go for prostitution and this is an easy way to make money,” she said.

The government does not have any data regarding the economic cost of the HIV. “We don’t have explicit data regarding the economic cost of HIV. As our population structure is young, it will affect the productivity of the country,” said Dr. Ram Hari Aryal, chief of Population Division at the Ministry of Health and Population.

“It is not only health issue but social and economic issue as well. It would have multiplier effects. Our population is young aged structured so we need to focus our policies on young population,” said Dr. Aryal, demographic expert.

Experts argue that Nepal 's inherent socio-economic ills make the country quite vulnerable to the epidemic though reportedly the prevalence rate is still low. Commercial sex work is rampant and trafficking of women for sex work in the brothels in Indian cities is a perennial problem. Migration, increasing Injecting Drug Use and acute marginalization of people make Nepal an easy target for HIV. Highest prevalence rates are found in the Central Region.

Prevalence of HIV

HIV infection has been noted in all regions of the country, although HIV infection appears to be concentrated in urbanized areas and districts with high labor migration.

Avoiding a full-blown epidemic is possible, but it will take effort across entire societies to make HIV/AIDS everyone’s business.  The region’s political leaders have to show the way with commitment and leadership.  But this will not be enough.  It will also take the sustained dedication of civil society leaders.

HIV/AIDS is still commonly seen as a problem to be dealt with by the health departments, doctors and health workers alone.  The only way to move effectively and faster than the HIV/AIDS epidemic is to attack it from all angles.  This means including it in the school health curricula and encouraging heads of universities to get involved to break the silence and stigma.

Businesses, of course, have a key communications and advocacy role early in the epidemic.  They will feel the impact of the AIDS epidemic as it evolves through their workforce, with direct consequences for a company's bottom line.

The cost of doing nothing includes increased medical expenditures and health insurance costs, funeral and death benefits, as well as higher recruitment and training needs due to lost personnel.  Other financial impacts include the effects of higher absenteeism and staff turnover, reduced productivity, declining morale and a shrinking consumer base.  And  while revenues shrink, costs of doing business rise due to disruptions in supply chains similarly affected by an epidemic.  For all these reasons, the early involvement of the private sector is critical to curbing the epidemic.

Behavioral and sero-prevalence data indicate the 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. For Nepal this would mean that around 100,000-200,000 young adults will become infected and that overall 10,000-15,000 annual AIDS cases and deaths may be expected.

High Rates of Migration and Mobility: Estimates of internal and external migration for seasonal and long-term labor range from 1.5 to 2 million people. It is necessary for the economic survival of many households in both rural and urban areas. Removal from traditional social structures, such as family, has been shown to promote unsafe sexual practices, such as having multiple sexual partners and engaging in commercial sex. Government and Institutional Framework: In 1988, the Government of Nepal launched the first National AIDS Prevention and Control Program. In 1995, a national policy was formulated, emphasizing the importance of multi-sectoral involvement, decentralized implementation, and partnership between the public, nongovernmental organizations, and the private sector. 

It also called for coordinated monitoring and evaluation, promoting actions for safe practices, counseling, and services to people living with AIDS. Provisions were made for reducing stigma and discriminatory practices against people living with HIV/AIDS, confidentiality of blood testing, and safe blood transfusion.

Towards this effort, Nepal has established a National AIDS Council (NAC) chaired by the Prime Minister. In addition, a multi- sector National AIDS Coordinating Committee (NACC) chaired by the Minister of Health has been established.  The NAC was meant to set overall policy, lead national level advocacy, and provide overall guidance and direction to the program. The NACC, on the other hand, was expected to lead the multi-sector response, and to coordinate active participation of all sectors in the fight against HIV/AIDS. However, both the NAC and the NACC have essentially been non-functional. Each has met only once or twice and activating these entities is a great challenge.

Antiretroviral treatment protocol has been endorsed by the Ministry of Health and Population, and treatment has been started on a limited basis. Initial focus, being undertaken with the assistance from UNICEF, is on preventing mother-to-child transmission.

Non-Governmental Organizations (NGOs). Numerous private and voluntary organizations implement HIV/AIDS activities funded by donors. There are currently almost 100 NGOs working in the area of HIV/AIDS. NANGAN, a consortium of NGOs in Nepal , is working to coordinate and share information, education, and communication materials, experiences, and lessons learned. The National Network Against Girl Trafficking, a coalition of approximately 40 NGOs initially established to tackle the problem of girl trafficking, has also begun to address the issue of HIV/AIDS.

The UNAIDS coordinates a theme group based in Kathmandu, and, between 1990 and 1999, the UN system supported the national response in Nepal with approximately US$5 million to build capacity, integrate HIV/AIDS into reproductive health services, and initiate a decentralized response.

WHO has provided funds and technical support. Other donors include the European Union, DFID (Department for International Development), Germany , Switzerland , and USAID. The USAID provides through its cooperating agencies the largest fund for HIV/AIDS interventions in Nepal , including surveillance activities, condom social marketing, as well as communication and advocacy programs.

There is an urgent need to e mphasize HIV/AIDS as a development issue with continued high-level leadership. The epidemic cannot be tackled through medical/clinical interventions alone. HIV/AIDS prevention and control requires a multi-sectoral approach, involving sectors other than health, such as education, women’s affairs, information, law and order, defense, agriculture, labor and transport.

Although Nepal has historically been viewed as a country with low HIV prevalence, recently it has registered marked increases in HIV/AIDS.  From the first case of AIDS in 1988, an incidence of 10,000 HIV-infected persons was estimated by 1994; between 15,000 and 20,000 by 1996; and 33,000 by the end of 2000.

Self-reports of ever-experience of STDs among Nepalese youth are underestimated in survey data, as are reports of sexual experiences with a non-regular sex partner.  The proportion ever having at least one sign or possible symptom of STIs is higher among girls than boys (girls 14%, boys 4%).  Among factory workers who had experienced at least one type of sign and symptom, slightly over one-fourth of them sought treatment.  It is discouraging to note that over three-fourths of the girls did not seek treatment for their STI-related problems and reported that they were too embarrassed to get check-ups. 

Most at-home deliveries take place without any professional assistance, with 55% attended by relatives and friends.  Therefore, representative data on the extent of syphilis or gonorrhea are not available.

Although knowledge of HIV/AIDS is pervasive within the general Nepalese population, there is little knowledge of HIV/AIDS among the small sample of M-M interviewed in Kathmandu .  Even those men who had heard of HIV and/or AIDS had poor understanding of the health issues involved.

STATE OF THE EPIDEMIC

The first case of AIDS in Nepal was reported in 1988. Since then, the numbers have rapidly risen among the country’s 24.1 million people. By early 2005, more than 800 cases of full-blown AIDS and over 5000 cases of HIV infection were reported officially.   

However, given the limitations of Nepal ’s public health surveillance system, the actual number of infections is expected to be much higher. The UNAIDS estimates that 62,000 people were living with HIV/AIDS at the end of 2003. Three times as many men are reported to be infected as women.
The main mode of transmission continues to be through commercial sex and the fact that the sexually transmitted disease (STD) rates are rising is an ominous sign.

According to a WHO/UNAIDS estimate at the end of 2003, 940 children below the age of 15 in Nepal were living with HIV/AIDS. UNICEF estimates that AIDS has orphaned 13,000 children, and the numbers are expected to increase in the years to come.