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Final Report for the
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Table of Contents II. Background and Country Context (See Below) III. Country Program Description A. Introduction Background and Country Context Nepal is a landlocked country with a population of twenty million, a literacy rate of 40 percent, and per capita income of USD $202. It is a country of contrasts with the Himalayan mountains, middle hills, and open plains bordering India. More than 90 percent of the population live in rural areas. Ninety-nine percent of Nepal's doctors live in urban areas and the ratio of population to health posts is 25,500 to one. About one half of Nepal's population lives in the Terai, central Nepal, with twenty percent of the land area sharing a border with India. Studies and migrant labor patterns show Indian transport and migrant workers and traders crossing the border into Nepal, and Nepalese labor, working in this agricultural/industrial area, returning from India. Consequently, the rate of high-risk commercial sex in the border areas and along Nepal's major transport routes is the highest in the country and the area most in need of STI/HIV/AIDS prevention interventions. Nepal also has a unique situation with regard to the number and mobility of female commercial sex workers (CSWs) and young males who work in India. Large numbers of young Nepalese girls are recruited as CSWs to Indian cities, and large numbers of young Nepalese males working in India frequent CSWs there. Thus, in addition to the increasing number of HIV infections occurring among STI patients (male and female) and female CSWs in Nepal, there are also increasing numbers of Nepalese CSWs and young male Nepalese workers who will be returning to Nepal over the next 5 to 10 years. The number of Nepalese CSWs in India has been estimated to range from a low of 20,000 to 100,000 or more. With HIV infection rates among CSWs in Indian cities ranging from a minimum of 1 percent to 2 percent, and up to 50 percent or higher, the estimated annual numbers of HIV-infected Nepalese CSWs and young males returning or being returned from India currently may range from a few hundred to a few thousand. Thus, in addition to the difficulties of developing prevention and control of HIV within Nepal with limited staff and resources, Nepal's National AIDS Program will have to also respond to the increasing number of HIV infections among Nepalese men and women returning from work in India. A. Epidemiology The first case of AIDS in Nepal was detected in a foreign visitor in 1988. During the early 1990's HIV seroprevalence surveys, conducted by His Majesty's Government's (HMG) National AIDS Prevention and Control Project (NAPCP), showed a gradual increased prevalence of HIV infection among STI patients and female commercial sex workers (CSWs) throughout most regions of Nepal. As of March 1993 a total of 124 persons with HIV infection had been reported. At the startup of the AIDSCAP/Nepal project in late 1993 His Majesty's Government reported a cumulative total of 188 HIV infections in Nepal. By August 1994, 32 AIDS cases and over 200 HIV infections had been reported to HMG. This increased to a cumulative total of 87 AIDS cases and 480 HIV infections as of January 1997, and at the close of the project in June 1997, the cumulative report included 647 HIV positive persons (44 percent female and 56 percent male) and 136 AIDS cases (45 percent female and 55 percent male). No specific studies were available to estimate how incomplete, inaccurate, or delayed such reports might have been, given the limited HIV/AIDS surveillance system in place. According to a consultant epidemiologist from the University of California, the actual number of AIDS cases might have been five to ten times the reported number and the actual number of HIV infections prevalent in Nepal might have been twenty to thirty fold greater than the detected number. Nepal's HIV Surveillance The first round of HIV sentinel surveillance (HSS) in Nepal was carried out in November, 1991. The sample sizes in each of the eight sentinel sites were very small -- most were less than 50. Several population subgroups who are at low risk of HIV infection, such as antenatal women and hospital patients, including tuberculosis (TB) patients, were included. The only HIV positive blood specimens detected were from CSWs in Nuwakot District (1/60), and Dharan in Morang District (4/40). Kathmandu was not included as a sentinel surveillance site during this first round of surveys. The second round of HIV sentinel surveillance was carried out in April and May 1992 from eight sentinel sites, including Kathmandu. Blood specimens were collected from sexually transmitted infection (STI) patients and female CSWs at all of the sentinel sites. In Kathmandu, Dharan and Pokhara, additional groups such as injecting drug users (IDU), antenatal women (ANC) and TB patients were also included. Sample sizes from were very small from IDUs, but were, in general, adequate for the other groups, averaging about 200 from each. HIV positive blood specimens were found only in the STI and CSW groups, with prevalence levels averaging 0.56 percent among STI patients and 0.72 percent among female sex workers. The major finding from this round of sentinel surveillance was that HIV infections were found in almost all of the sentinel sites, although at relatively low (< 1 percent) levels. The third round of HIV sentinel surveillance, carried out six months later, showed very similar findings, but the average HIV seroprevalence among STI patients and sex workers increased to 0.79 percent and 1.28 percent respectively. In the fourth round of sentinel surveillance carried out in May and June 1993, the average HIV seroprevalence increased to 1 percent among STI patients, but a slight decrease to less than 1 percent was found among female CSWs. At this time the first HIV infection in a low HIV risk group was found in one of the 605 antenatal women tested in Pokhara. The protocol for HIV sentinel surveillance (HSS) was radically changed for the fifth round which was carried out during June and July, 1994. The number of sentinel sites was reduced to five, only STI patients were included, and the sample size at each site was increased to about 400. No increased HIV prevalence was found among STI patients at any of the sentinel sites compared to the findings from round four one year earlier. In the 1995 rounds (April-May, and November), HIV rates among STI patients remained at about 1 percent in Kathmandu and Pokhara, but were much lower or zero at the other sites. At least one HSS round was carried out during 1996, but the HSS protocol was not uniformly implemented in all sites because of staff turnover in the National Centre for AIDS and STI Control. It can be concluded from the limited HSS data available that HIV infection rates among the highest risk "groups" continue to be relatively low (i.e., averaging about 1 percent or less). However, there are some HIV/AIDS data, aside from the HSS data, and trends that suggest that overall HIV prevalence is beginning to increase. During 1996, the prevalence rate of HIV infection among blood donors in Nepal was found to be close to 1/1,000 (39/42,500), which is about a threefold increase compared to 1995. In addition, the number of reported AIDS cases more than doubled in 1996 (37) compared to the number reported in 1995 (15). Collectively, these data suggest that the HIV epidemic in Nepal continues to grow, albeit at a relatively much slower rate compared to the HIV epidemics documented in other Asian countries such as Thailand and Cambodia. HIV Estimates and Projections In October 1994, the AIDSCAP consultant epidemiologist and the National Centre for AIDS Control had estimated that there were about 10,000 prevalent HIV infected persons in Nepal. Based on the additional data collected since then, their update of this estimate, through the end of 1996, would be from 15,000 -20,000 HIV infections, with a large proportion (up to half) of these infections acquired in India. B. Policy His Majesty's Government's Response to HIV/AIDS In 1987 Nepal's Ministry of Health (MOH) created the National AIDS Prevention and Control Project (NAPCP) with assistance from WHO/GPA. In 1990 the NAPCP implemented a Medium Term Plan (MTP) through 1992. In 1992 the National AIDS Coordination Committee (NACC) was established bringing together government and nongovernmental representatives with the NAPCP serving as HMG's focal point. In 1993 the NAPCP launched a Second MTP, covering the period 1993-1997. Through a multisectoral response, the new plan aimed to prevent the sexual transmission of HIV, as well as through blood products and perinatal transmission, and to reduce the impact on individuals and families. Starting in 1994, HMG utilized the Red Cross to screen blood sources used in government health facilities. Up to one hundred percent of the nation's blood supply was presumed to be screened for the AIDS virus, and the majority of blood donors in Nepal were voluntary rather than paid. With support from the European Economic Community (EEC) in 1993, more focus was placed on STI prevention and control activities. The NAPCP initiated the development of Nepal-specific STI case management guidelines. In 1994 draft guidelines were developed, tested and finalized in 1995 with the assistance of EEC, AIDSCAP and national STI experts. In 1995 the NAPCP was merged into the larger National Centre for AIDS and STI Control with an increased staff and mission of coordination. The finalized guidelines, "The National STD Case Management Guidelines" were published by the NCASC and widely distributed to government, NGO and private sector physicians and other health providers in an effort to promote widespread use of the syndromic approach to STI control and management nationwide. The NCASC manages HMG's HIV and STI sentinel surveillance system currently implemented in five regions. The NCASC sentinel surveillance program conducts biannual rounds and issues an annual sentinel surveillance report. In 1995 the NCASC was engaged in the development of a draft national policy on HIV/AIDS which was presented for parliamentary approval in early 1996. The 1996 National Policy on AIDS and STI Control included a commitment by HMG to manage HIV/AIDS and STI prevention on a priority basis with appropriate financial and human resources to be implemented as a multisectoral program. The 1996 national policy reformed the NACC with a total of 40 members from the health and various sectors to oversee the National AIDS Programme. The NACC is now supported by an Executive Committee under the chair of the Health Secretary. To encourage decentralized HIV/AIDS programming the District AIDS Coordination Committee (DACC) was created. While the NACC is the highest body to determine HIV/AIDS and STI policy, the NCASC, under the Department of Health Services, continues to serve as HMG's focal point for HIV/AIDS and STI prevention activities. The 1996 National Policy instituted the following twelve articles:
The approval of a national HIV/AIDS policy served to highlight significant structural changes in HMG's multisectoral response to HIV/AIDS efforts to combat HIV/AIDS and other sexually-transmitted infections. In addition to the Ministry of Health, the Ministries of Communications (including Nepal Television and Radio Nepal), Education, Women's Affairs, and Home Affairs have supported efforts to transmit prevention messages, information, education and services to Nepalese at-risk. It is particularly important to recognize the Ministry of Communications' agencies, Nepal TV and Radio Nepal, for their supportive efforts to provide appropriate time slots and ongoing encouragement to air sensitive safer sex messages on the nation's only electronic mass media channels. Nepal has been a communications pioneer in South and Southeast Asia in its ability to support a targeted condom/behavior change campaign for its national audience, despite numerous changes in the central government over the past few years. External Review of the National Program In late 1996 the National AIDS Program was reviewed by an external team to assess progress since 1992. The review team focused its review on the process and activities of the program rather than its achievements. In its January 1997 report the review team issued the following consensus statement:
The key findings of the mid-term external review were that: a national policy and plan had been formulated based on a multisectoral approach, the National AIDS Program (NAP) had been institutionalized within the governmental system, NGO activities had reached the grassroots level, coordination had become more effective at the central level, and multisectoral involvement in AIDS and STI prevention had been initiated. The review team noted the major constraints as: limited coverage and limited resources to implement AIDS/STI prevention activities, the lack of appropriate trained human resources to implement AIDS/STI prevention activities in various sectors, poor coordination and cooperation with various departments and organizations carrying out prevention activities, the lack of terms of references, working guidelines and mechanisms for the District AIDS Coordination Committee (DACC), and weaknesses in planning and interventions at the district level. The major recommendations of the external review included: the integration of AIDS prevention activities, mobilization of the DACC for improved coordination, adequate resource mobilization, the training of human resources at various levels, the development of an effective mechanism for good coordination and cooperation among partners working in the field of AIDS and STI prevention, the development of clear guidelines for the DACC and implementing partners, and regular reporting of activities. A key finding of the external review team focused on Interventions for Targeted Groups -- more precisely the AIDSCAP Central Region-based strategy. The team identified the following Constraints with the AIDSCAP interventions:
The review team's concluding Recommendations included the following:
For future HMG programming the external review could not have been better timed, as the report findings and recommendations were utilized in the NCASC's strategic planning process currently underway to develop a draft new Medium Term Plan for HMG's 9th Five-year National Strategic Plan for the period 1998 - 2002. The Response to HIV/AIDS in Nepal Up until 1993 the major focus of HIV prevention programming was coordinated by the NAPCP/NCASC, with support from WHO/GPA, limited support from international nongovernmental organizations (INGOs) and a small number of NGO's pioneering efforts in AIDS prevention. In 1993 Nepal's HIV/AIDS sector experienced rapid change resulting from huge investments and interests by international donor agencies and INGOs in HIV and STI prevention programming in Nepal. The European Economic Community (EEC) led the way with a commitment to strengthen HMG's national STI control program through the provision of direct financial and technical assistance. At this time USAID/Nepal commissioned a team from Family Health International's AIDSCAP Asia Regional Office to visit Nepal and review the HIV/AIDS epidemiological situation and propose a series of interventions for future USAID support. AIDSCAP's Memorandum of Understanding between USAID - NAPCP - FHI/AIDSCAP was signed in August 1993 launching USAID's commitment to support private and nonprofit sector initiatives among commercial sex workers and their clients in Nepal's Terai regions. At the same time the US-based NGO, the American Foundation for AIDS Research (AmFAR) initiated a program to fund seventeen local NGOs to implement community-based AIDS prevention and research programs throughout the country. In 1994 UNDP launched a three-year community-based program in direct collaboration with the NCASC in six districts. These large, new programs were complemented with an increase in resources and assistance from donors and INGOs working in family planning or related health activities with the integration of direct and indirect HIV/AIDS and STI programming approaches from 1994-96. This included organizations such as Swiss Development Corporation, UNFPA, SAVE/US, Care, GTZ, United Mission to Nepal, CEDPA's ACCESS project with Nepal Red Cross, The Asia Foundation, The Adventists' Relief Agency, and IPPF through the Family Planning Association of Nepal. Resulting from this influx of outside funding, Nepal experienced an emergence in 1994-1995 of its NGO sector working in HIV/AIDS prevention and control. As of late 1997 it was estimated that up to 100 NGOs were working in the area of HIV/AIDS. The comparative advantage of NGOs is their ability to interact with population groups that are hard to reach and often socially or economically marginalized, such as commercial sex workers (CSWs), migrant laborers and injecting drug users. In addition to NGOs, other for-profit and nonprofit sector organizations are pursuing HIV/AIDS and STI interests. These organizations include agencies working in direct partnerships with INGOs/donors as well as affiliated organizations, e.g., AIDSCAP's association and private sector partners -- Nepal Medical Association; Nepal Chemists and Druggists Association; trucker's or truck owners associations; the social marketing concern -- Nepal Contraceptive Retail Sales Company; Nepal Jaycees; advertising firms; and private providers and clinics. While many organizations are working to combat HIV/AIDS and STIs in Nepal a program weakness is coordination and collaboration. Perhaps this will be strengthened with the 1996 national policy, the reformed NACC, and the inclusion of the external review recommendations into the 1998 - 2002 National Strategic Five-year Plan. |
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