Core Package Final Report

CORE PACKAGE FINAL REPORT:

A Pathway to Stopping the Rapid Spread of HIV/AIDS in Nepal: Increasing the Participation of Affected Groups in Designing Effective Policies and Programs

POLICY Project November 2005

This publication was produced for review by the United States Agency for International Development. It was prepared by the POLICY Project.

A Pathway to Stopping the Rapid Spread of HIV/AIDS in Nepal: Increasing the Participation of Affected Groups in Designing Effective Policies and Programs

POLICY Project

November 2005 The POLICY Project is funded by the U.S. Agency for International Development (USAID) under Contract No. HRN-C-00-00-00006-00. POLICY is implemented by Futures Group in collaboration with the Centre for Development and Population Activities (CEDPA) and Research Triangle Institute (RTI). The views expressed in this report do not necessarily reflect those of USAID or the United States government. Contents

Acknowledgments iv

Abstract v

Abbreviations vi

I. Introduction 1

II. Background Information 2

III. Project Approach 7

IV. Project Activities 8

V. Recovering Nepal’s Achievements 16

VI. Implementation Challenges 22

VII. Future Perspectives on Recovering Nepal 26

References 29

Nepal Core Package Final Report iii Acknowledgments

None of these activities could have happened without the significant contributions of many individuals. Recovering Nepal would like to thank and acknowledge the following people:

POLICY Project/DC Organizations Anne Eckman Asia Harm Reduction Network Britt Herstad Canadian AIDS Society Chris Ward Chicago Recovery Alliance Felicity Young Community Recovery Center Jane Begala Community Support Group Lane Porter DFID/Nepal Nancy McGirr Family Health International/Nepal Philippa Lawson Freedom Center Gurkha Army Ex-Servicemen’s Organization POLICY Project/Nepal Himalayan Broadcasting Corporation Bhojraj Pokharel Lumbini Support Group Resham Gurung Metro FM Shreejana Ranjitakar National Association of People Living with Sumi Devkota HIV/AIDS in Nepal Nava Kiran Plus Consultants Nepal Plus David Burrows Nepal Youth Rehabilitation Center Ivana Lohar, UNDP Oxygen Research and Development Forum Jesse Brandt Richmond Fellowship Nepal (men and women) Kate Thomson, UNAIDS Sahara Home Rehabilitation Center Robin Contino Support Groups from various parts of country UNAIDS Recovering Nepal UNDP Executive Board and Advisors USAID/Washington/OHA/IS/ Ambika Khanal USAID/Nepal Anand Pun Youth Vision VCT Service Center Anjan Amatya Bijay Pandey Others Bikash Nepal Anjana Neupane, Journalist Bishnu Sharma Corona Productions Ekta Mahat Punarjeevan Kendra Dharan Kumar Gurung Puspa Tandukar Mahesh Manandhar Raj Kumar Dikpal, Journalist, Annapurna Post Min Sen Roshani Dhungana Rajiv Kafle Rickson Bajracharya Ujjwal Karmacharya Umang Rai

Nepal Core Package Final Report iv Nepal Core Package Final Report v Abstract

In 2003, the POLICY Project implemented a core package in Nepal, which was designed to create a model for increasing the meaningful participation of injecting drug users (IDUs) in the HIV/AIDS policymaking environment. Activities centered on bringing together recovering IDUs to form a network, thereby developing their leadership capacity and knowledge of HIV prevention in order to advocate for HIV treatment, support, and care. This report describes how the project took on a life of its own and helped transform a loosely organized network into an established nongovernmental organization (NGO). The following list exemplifies the breadth of the project’s achievements:

 Nepal’s first IDU network was created, which united IDUs and increased their leadership capacity.  549 IDUs participated in training sessions throughout the country.  IDUs advocated with donors and policymakers for care, treatment, and support, including free drug rehabilitation services, for people living with HIV/AIDS (PLHAs).  IDUs developed strategic relationships among themselves and with policymakers, donors, and HIV service and drug rehabilitation organizations.  The network successfully used the media to raise awareness of stigma and discrimination against IDUs and PLHAs.

Nepal Core Package Final Report vi Abbreviations

AG advisory group AIDS acquired immune deficiency syndrome ATS amphetamine-type substances CCM country coordinating mechanism CREHPA Centre for Research on Environment, Health, and Population Activities DFID Department for International Development (UK) FGD focus group discussion FHI Family Health International GIPA greater involvement of people living with HIV/AIDS HIV human immunodeficiency virus HMG His Majesty’s Government of Nepal IDU injection drug user MMP methadone maintenance program MMT methadone maintenance therapy MOHP Ministry of Health and Population MOHA Ministry of Home Affairs NCASC National Centre for AIDS and STD Control NGO nongovernmental organization PLHA people living with HIV or AIDS RN Recovering Nepal SACTS STD/AIDS Counseling and Training Service STI sexually transmitted infection TA technical assistance UN United Nations UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNICEF United Nations Children’s Fund USAID U.S. Agency for International Development

Nepal Core Package Final Report vii I. Introduction

In most Asian countries, programs that seek to increase the participation of injection drug users (IDUs) in the fight against HIV/AIDS have been small, scattered, and not systematically documented and evaluated. The status of these programs is partly due to a lack of understanding of the need to prevent HIV transmission among IDUs and the extreme stigma and discrimination IDUs face in many countries—including Nepal, where injection drug use has increased and is having an affect on HIV prevalence rates.

In 2003, the USAID-funded POLICY Project initiated a core package aimed at expanding IDU participation in the fight against HIV/AIDS in Nepal. The initial concept and impetus for this project originated from discussions between a member of the IDU community and POLICY staff in Kathmandu, who were eager to initiate advocacy work with vulnerable groups such as IDUs.

This report documents POLICY’s role in achieving a supportive environment for policy reform by increasing IDUs’ participation and leadership. To fully understand and appreciate the magnitude of the project’s accomplishments, the report describes the status of HIV/AIDS and IDUs in Nepal when the project began, along with an assessment of the policy environment. The report also looks at lessons learned from the project, as they will have regional and global relevance and will support the exploration of innovative and more effective interventions for addressing the HIV-related harm associated with injection drug use.

Nepal Core Package Final Report 1 II. Background Information

Drug Use in Southeast Asia

Since the 1970s, illicit drug production and consumption have grown enormously in most of East and Southeast Asia, with an initial focus on opium and heroin and a recent concentration on amphetamine-type substances (ATS). New populations have been exposed to illicit drug use because of rapid growth and the movement of drug trafficking routes. As a result, there has been a massive increase in illicit drug use—largely injecting opiates and ATS—particularly among young men in many parts of Southeast Asia. This drug use is associated with poverty, internal migrant labor, cross-border mobility, and uneven economic development.

People who inject various types of drugs in veins or muscles are defined as injection drug users. Asia is now estimated to be home to one-half of the world’s 15–20 million IDUs. Illicit drug use may lead to unsafe injection practices and sexual practices. It is common for IDUs to inject one another and generally there is little time to sterilize injecting equipment between uses. In addition, the cleaning of injecting equipment is inadequate. Saliva, urine, and cold and hot water are commonly used and some IDUs use bleach. A 1999 survey of 92 methadone clients in Nepal found that 36 percent shared injecting equipment (Shrestha, 1999).

Drug Use and HIV/AIDS in Nepal

Care, treatment, and support must go to this group [IDU] in order to contain the HIV epidemic in Nepal —Dr. Chowdary, National Centre for AIDS and STD Control (NCASC), MOH

While injection drug use has affected other countries in this region for the past 20–30 years, it is now making inroads in Nepal. Although the practice of taking drugs such as cannabis (ganja) has existed in Nepal for centuries, a significant shift to injection drug use occurred in the early 1990s and is increasing as a result of persistent poverty and the availability of cheap synthetic heroin. While substantiated estimates of IDUs in all major Nepali towns and cities are not yet available, recent systematic mapping reveals a range from 600 (Pokhara) to 5,000 (Kathmandu Valley) (FHI and CREHPA, 2003 in FHI and NCASC, 2004). In addition, the government of Nepal estimates that there are 50,000 illicit drug users, of whom 20,000 are IDUs. It is likely that the actual number of IDUs is substantially higher (Reid and Costigan, 2002). Since there is extreme stigma in being a female IDU in the Kathmandu Valley, female injectors are much more hidden and at greater risk for HIV and other risks associated with drug use than male injectors.

Nepal Core Package Final Report 2 Drug Use in Nepal

There is no such thing as a typical Nepali drug addict. He or she may be young to middle age, illiterate to highly educated, or come from any sphere of society. Yet drug addicts are stereotyped as immoral, emotional, weak-willed people with physical and financial problems. The problem lies in the fact that there is a lack of detailed information and intelligence on the user and trafficking of drugs throughout Nepal. Codeine-based syrup, burpernorphine, diazepam, nitrazepam, etc. are the common psychotropic drugs sold and consumed. Cannabis is the main drug of abuse, followed by codeine-based cough syrups (phensedyl/corex), opiates (nitrazepam/diazepam), buprenorphine (tidegesic) and heroin. None of these drugs are manufactured in Nepal. Moreover, use of codeine phosphate in cough syrups is banned in Nepal. However, these drugs are easily smuggled in from India, where they are widely manufactured, both legally and illicitly. Cannabis can be found growing widely in abundance, especially in the mid-west, central, and the far western parts of Nepal.

Drug abuse in Nepal has always been a matter of concern. Local use of cannabis is widespread and is a part of religious and cultural traditions. Similarly, alcoholism is another addiction that has retained “social acceptability,” though it is the single biggest medical and social problem in Nepali society because of its cultural acceptability. Use of cannabis and alcohol has always been clouded by other addictions like injecting and using other hardcore drugs. The effect and extent of drugs and drug-related problems are becoming increasingly visible in present time. —Comments from recovering drug users, Recovering Nepal

HIV prevalence has generally followed drug trafficking routes into areas where injecting has increased. Once introduced into a network of IDUs, HIV spreads with explosive rapidity. With conditions conducive to rapid widespread transmission of HIV among the general public, HIV prevalence in Nepal is projected to rise to between 1–2 percent of the population within the next few years (Saidel et al., 2003). At this speed, a generalized epidemic is possible in the next 5–10 years. In 2003, there were an estimated 61,000 PLHAs and 3,100 AIDS-related deaths in Nepal (UNAIDS, UNICEF, and WHO, 2004).

HIV prevalence data among IDUs (see Table 1) suggest that Nepal has progressed from being a low-risk country with low HIV prevalence rates to a country with a concentrated epidemic (currently estimated at approximately 0.2–0.5 percent of the population). HIV prevalence is concentrated among IDUs, female sex workers, and men who have sex with men. Prevalence among street-based female sex workers was 17 percent; however, the rate among sex workers who inject was nearly 75 percent (New Era/SACTS, and FHI, 2002).

Nepal Core Package Final Report 3 Table 1. HIV Prevalence Among Injection Drug Users

Location HIV Prevalence (%) Survey Reference Year National (11 Towns) 40 1999 Karki (2000) Kathmandu 2 1991 NCASC (2004) Kathmandu 3 1992 NCASC (2004) Kathmandu 50 1999 Karki (2000) Kathmandu 68 2002 New ERA/SACTS and FHI (2002) Pokhara 22 2003 New ERA/SACTS and FHI (2003b) Eastern Terai 35 2003 New ERA/SACTS and FHI (2003a)

The government, businesses, NGOs, and donors acknowledge HIV/AIDS as a serious development issue for Nepal. As a result, they are beginning to focus on prevention and other effective ways of reducing the risk of HIV transmission among IDUs and their sex partners. HIV epidemics among IDUs will receive continuous attention in addressing the overall epidemic for the following reasons:

 Countries with IDU HIV epidemics are beginning to deal with large numbers of people dying from AIDS-related causes and becoming sick, with little infrastructure in place to address their needs.  Heterosexual transmission of HIV from IDUs to their sexual partners can greatly increase the spread of HIV in the community. This increase is compounded where a high proportion of sex workers inject drugs, as is increasingly seen in Southeast Asia, and where a high degree of sexually transmitted infections (STIs) exists.  Epidemics of other communicable diseases—including tuberculosis, hepatitis B and C, and STIs—can also expand rapidly.

Services for IDUs in Nepal

Even though people who inject drugs are at the center of the HIV epidemic, there are no dedicated government drug rehabilitation treatment agencies or centers in Nepal. Where drug treatment is available, it is almost exclusively accessed by men—since they often control the resources and receive more family support. The treatment is provided by local and indigenous community-based organizations and NGOs and does not receive funding from the government or outside donors. Currently, there are more than 30 drug treatment centers in Nepal; however, some do not admit users infected with HIV or hepatitis B or C. Furthermore, some institutions practice mandatory HIV and hepatitis testing of clients admitted into their detoxification programs, which does not include pretest counseling. These institutions have a great need for HIV and drug prevention education and support and care.

Nepal Core Package Final Report 4 Although existing HIV prevention services for IDUs have increased, the overwhelming majority of IDUs is not being reached. Only 19 NGOs provide HIV prevention-related services—reaching approximately 10 percent of IDUs—and less than 3 percent receive drug rehabilitation services (Burrows et al., 2001). Furthermore, little evidence-based drug education reaches the general community. Upon arrest, rather than being offered the option of rehab, many male IDUs who do not have families that can afford treatment are placed in custody at police stations or are confined to jails.

Policy Environment

Government. While Nepal’s government was relatively stable at the beginning of POLICY’s work in this area, the political situation deteriorated as the project went on. During the project’s two years, there were six to eight changes in the leadership of the National Centre for AIDS and STD Control (NCASC), which is the national coordinating agency for HIV/AIDS. There were similar changes in other key leadership positions within the Ministry of Health and Population (MOHP) and the Ministry of Home Affairs (MOHA). This environment had a huge impact not only on IDUs and other advocates, but on the government and service delivery as a whole, as it became increasingly difficult to achieve momentum and policy change. Working with the national government at this time was more of a challenge than it would have been otherwise.

Legal framework. As drug use is illegal in Nepal, the government’s aim is to achieve “zero drug use.” However, there are no laws that specifically prohibit the use of methadone or other opioid substitution treatment (UNAIDS and UNDCP, 2000). Moreover, at the project’s inception, the MOHA and the MOHP had different mandates, roles, and goals related to addressing drug use and HIV issues. The processes of policy development and implementation for the control of illicit drug use and HIV/AIDS are entirely separate, as the former rests with the MOHA and the latter with the MOHP. The MOHA’s main focus is on reducing demand for drugs. The MOHP approaches drug use primarily from a health perspective, with a focus on reducing HIV-related risks (UNAIDS and UNDCP, 2000). This core package saw involving IDUs in the policy process as a central avenue for linking issues and addressing some of the confusion in the policy arena.

Coordination. Nepal provided an opportunity to build on previous work undertaken in drug control and substance use treatment facilities. As previously stated, there was an opportunity to coordinate between policymakers addressing HIV/AIDS issues and policymakers addressing drug use. Although this presented a considerable challenge, it was viewed as an opportunity. In addition to working with the MOHP, there was a great need to work with public security authorities to build their awareness and capacity to create effective strategies for preventing HIV transmission among and from IDUs. Additionally, collaborative linkages between public security and health authorities needed to be built so that both sectors could jointly develop a supportive policy environment for the implementation of effective future interventions.

The National HIV/AIDS Strategy, 2002–2006. When the project began, the National AIDS Council, headed by the prior Prime Minister, had endorsed the National HIV/AIDS

Nepal Core Package Final Report 5 Strategy, 2002–2006 (Government of Nepal, 2002). The strategy’s guiding principles (as follows) provided a strong foundation on which the core package was based:

 Multisectoral and interdisciplinary involvement is essential for building an adequate response to the HIV/AIDS epidemic.  The response to HIV/AIDS will be rights based, with a specific focus on the rights of people infected and affected by HIV/AIDS, and in particular, the right to confidentiality.  Resource allocations must correspond with defined priorities based on the vulnerability of various affected groups and communities.  People and communities must be empowered to protect themselves against HIV infection within a supportive environment.  Equal access to basic care and services must be guaranteed for all persons infected and affected by HIV/AIDS.  Gender considerations will be central to the development of programs and interventions.  Participation of “target groups” in the design and implementation of programs and projects is essential.  Emphasis must be on the involvement of PLHAs in the design and implementation of policies, strategies, programs, and projects.

Nepal Core Package Final Report 6 III. Project Approach

“By and for” IDUs

At the project’s start, in most Asian countries, there was little response to the issue of HIV/AIDS among IDUs by national governments, international nongovernmental organizations, international agencies, and regional bodies—despite the centrality of injection drug use to overall national and regional HIV/AIDS epidemics. Not only was there little recognition of the importance of preventing HIV transmission among IDUs, but there was and continues to be extreme stigma and discrimination against them. This core package was partially initiated to deal with precisely that issue—reducing stigma and discrimination against IDUs. In doing so, the core package employed ethical principles vital to engaging people who are traditionally discriminated against and who have had limited opportunities for advancement.

The project used a “by and for” approach, which posits that drug use is best understood by those who have experienced it; in other words, IDU leaders can make a crucial difference in advocating for IDUs’ needs. Specifically, the approach required that POLICY hand over the reins of the project to a group with the desire to develop the skills necessary to run such an undertaking. The IDUs asserted themselves in making sure this happened and POLICY supported them by strengthening their leadership ability and helping them to design effective strategies and actively engage in HIV prevention, support, and care decisionmaking processes.

While the project was initiated by POLICY/Nepal and POLICY/DC, IDUs pushed for the formation of an advisory group (AG), which played a key role in decisionmaking, planning, and implementation since its inception. The AG included 13 recovering IDUs (10 executive members and 3 advisors), who represented all the main regions of Nepal. Various leaders and coordinators carried out the project’s day-to-day activities under the AG’s guidance and the supervision of a project consultant and POLICY/Nepal and POLICY/DC staff.

Finally, the overall project approach was guided by the following principles:

 Use noncoercive selection processes;  Protect and respect an individual’s and his/her family’s safety;  Respect the right not to disclose one’s own or another’s personal information; and  Understand the risks and consequences that can be associated with disclosure.

Nepal Core Package Final Report 7 IV. Project Activities

National Consultation Meeting by and for IDUs

In July 2003, POLICY staff initiated the core package by sending a letter to drug rehabilitation centers, inviting them to send participants to the first-ever national consultation by and for IDUs in Nepal. The one-day meeting was the first of several key meetings that occurred over the project’s life. Held in Kathmandu, it was attended by 50 participants from nine districts throughout Nepal. Although it was “by and for” IDUs, POLICY took the lead in organizing it and worked with a small group of IDUs previously identified and trained to facilitate the meeting. The IDU trainers were selected as potential leaders by IDU-led substance use facilities.

After learning about the project’s goals, meeting participants discussed issues that IDUs should address to improve their quality of life in Nepal. Participants discussed the need to have laws and workplace policies in place to protect IDUs and PLHAs from discrimination and the need for unity among IDUs to work on education and information activities. They were led through exercises on developing leadership and training skills that were meant to inspire and motivate participants to help other IDUs realize their rights and improve their quality of life.

I felt immediately like it was a good program as no one else was focusing on IDUs. —AG and EC member

IDU response. The concept of “by and for” was relatively unfamiliar to drug users and other marginalized communities in Nepal. Understandably, it was initially met with much skepticism from many of the drug users invited to participate in project activities, as previous experience had led them to mistrust the motives of funding agencies. There was also confusion about what the project was actually aiming to do; for example, the name POLICY Project led some to believe they would be making policies on drug use.

In spite of the skepticism, the “by and for” concept was hard to resist once people understood the potential implications if it was successfully implemented. Because of the prevailing attitudes toward drug users in all cultures and societies, the realization that others believe in their potential can be extremely motivating and empowering.

IDU leadership. Based on evaluations, IDUs perceived that they were needed and valued for the first time as partners (“not just to answer a survey about how many times they inject or have sex”) and that they had the skills and motivation to help others. The IDUs held a meeting without POLICY to review the proposed design of the project and to determine whether they trusted and were committed to the process. This was a healthy

Nepal Core Package Final Report 8 display of independence and peer leadership. Following this meeting, they requested that two IDU coordinators be selected through an interview process, with “50 percent gender balance.” These coordinators were to lead the project and establish an AG of IDUs from six districts to help them with project coordination.

The two coordinators were recruited from the group of drug users who had attended the national consultation meeting. All interested applicants were asked to submit a basic resume, two letters of reference, and an English writing sample. They were interviewed by two former IDUs and POLICY Project staff. Among other duties, such as training preparation, the coordinators were given responsibility for organizing the AG meetings and acting as secretariats for the project. A technical assistance plan was formulated based on the AG’s request to improve their English and public speaking capacities as part of a priority effort to strengthen their leadership skills.

Nationwide focus group discussions (FGDs). In six regions of Nepal, during fall 2003, AG members conducted 19 FGDs with the aim to

 Increase understanding of the impact of HIV/AIDS and drug-related stigma and discrimination;  Build leadership and advocacy skills of IDUs to participate in HIV/AIDS policy dialogue;  Enable drug users to identify and highlight their own key issues and concerns in relation to capacity building; and  Improve understanding of drug users’ needs, access to services, and the impact of HIV on harm reduction and treatment for drug addiction services.

Both men and women—current and ex-drug users—participated, although the majority of participants were male. To facilitate discussion, there was a separate FGD for women. The AG’s involvement in this research was vital to successfully reaching out and involving other IDUs. Being former IDUs themselves, AG members were particularly sensitive toward the respondents and respected their views and confidentiality. During the FGDs, male IDUs highlighted a lack of access to drug treatment (especially outside of Kathmandu and for women), a lack of skills and education, rejection by family members and community, low self-esteem, discrimination by others, policy harassment, isolation, and a lack of trust (see Box 1). Regarding leadership and advocacy skills specifically, IDUs highlighted a need for training related to public speaking, increased knowledge of drug- and HIV-related issues, capacity to work with IDUs, and management and proposal skills. Data gathered through FGDs informed the creation of the National Leadership Training curriculum, later drafted by IDUs.

They are tired of giving interviews and talking about their problems to people who come to do surveys. They want practical action rather than talking and identifying problems and needs. Initially they refused to take part in

Nepal Core Package Final Report 9 the FGD but after convincing them this program was run by and for IDUs, they agreed to take part in it. —FGD Bharatput/Chitwan Box 1. Selected Issues Highlighted in FGDs with Male IDUs

Community Level  IDUs are harassed both by police and other members of society.  Seen as untrustworthy, IDUs are identified as immoral characters or criminals.  Health professionals often deny IDUs services.  Service providers and caregivers have judgmental attitudes toward IDUs.  There is a lack of drug treatment (government) facilities.

Family Level  IDUs are ostracized from their families and may face disrespect from children, siblings, and wives.  Society stigmatizes IDUs for assumed HIV status.  IDUs are seen as incapable of change.  Drug use is viewed as a crime or moral defect rather than a disease.  IDUs lack economic and emotional support.

Individual Level  The IDU community perpetuates discrimination itself by type of drug use.  IDUs encounter low self-esteem, isolation, hopelessness, and pessimistic attitudes.

Female IDUs highlighted similar issues, but also many others specific to their status as women (see Box 2). As one participant stated, “The boyfriend or husband often tries to escape out of the responsibility of his kids and the child has to suffer along with the IDU mother.”

Nepal Core Package Final Report 10 Box 2. Selected Issues Highlighted in FGDs with Female IDUs

 Gender-based discrimination from all levels and everywhere  Misconception that all female IDUs support their drug habit through prostitution  No support from service providers and no facilities for women  Children with IDU mothers are discriminated against  Discrimination from male IDUs, (i.e., male friends suggest not to marry an IDU)  Judgmental attitude and ignored by service providers  Female IDUs face more discrimination if HIV positive  Low self-esteem  Feeling of weakness without male partner  Hopelessness  Difficult to form relationships/difficult to marry (even another IDU)  Competitive to gain one of the only eight spaces in all of Nepal for female rehabilitation center  Lack of trust by husband or boyfriend

National Leadership Training

In February 2004, the project held a National Leadership Training in Pokhara, attended by 38 participants from all the major regions of Nepal. The training was organized, implemented, and facilitated by recovering IDUs (who had participated in the national consultation) with technical, logistical, and mentoring support from POLICY. The facilitators were trained for five days prior to the training. The goals, which were reflected in the training curriculum, were as follows:

 Improved skills for public speaking—enabling participants to acquire the basic skills needed for public speaking  Increased knowledge of HIV/AIDS—enabling participants to tell fact from fiction by sharing basic information on HIV/AIDS  Increased knowledge on drug and harms related to use, including relapse— enabling participants to learn about drug-related harm and HIV  Increased knowledge on available services—enabling participants to identify ways to provide practical care and support to active, recovering, and relapsed drug users and those who have HIV  Increased skills to support and educate other drug users on HIV and drug use—enabling participants to access existing HIV and drug user services available in Nepal  Understanding of how to use this training in the community—enabling the participants to obtain basic facilitation skills and identify approaches and strategies to use their skills to help address drug use and HIV in their community

Nepal Core Package Final Report 11 Participants work on a district-level replication plan

Throughout the training, participants practiced their new public speaking skills in an effort to become leaders in their communities. The workshop ended with the preparation of action plans for replicating the leadership training. Evaluations revealed that 70 percent of the participants rated their increased knowledge of HIV as excellent or good (see the below figure).

Knowledge of HIV and AIDS Following Training

Least 6% Okay 6% Average 18%

Excellent Least 52% Okay Good 18% Average Good Excellent

Nepal Core Package Final Report 12 Legacy of the National Leadership Training. A generation of IDU leaders emerged from this training, which created the opportunity for everyone involved to gain and learn from new experiences, interactions, relationships, and knowledge. At its closing, the AG initiated the Pokhara Declaration, which was a petition inviting and encouraging the IDU community to stay unified and committed to create change. Members signed the declaration, which was adopted as a meaningful symbol of IDU involvement in Nepal. It reads as follows:

In order to bring a momentum of this movement of injecting drug users (IDUs) leading and helping each other, we hereby declare that, all IDU leaders will maintain regular contact with each other so that we can build a relationship among us. This will help us to unite and build a network of IDUs, which will give us strength to fight for the rights of all IDUs throughout the kingdom of Nepal.

Participants of the National Leadership Training

Network of Recovering Nepal. The leadership training inspired the network of drug users to name itself Recovering Nepal (RN). The AG members for the newly named network remained the same, and the core package operated under that name from that point on.

Nepal Core Package Final Report 13 Replication of the leadership training. After the workshop in Pokhara, AG members replicated the training in 20 sessions across five regions of Nepal. In total, 350 IDUs (15 women)—including both current and recovering users—were trained.

The IDU facilitators and the training inspired participants to become leaders in their own communities. Participants reported that the issues covered broadened their knowledge and clarified myths about drug addiction and HIV. The detailed information about services and their gaps enhanced the participants’ knowledge on how to access assistance. In addition, training participants were excited and impressed by the greater involvement of people living with HIV/AIDS (GIPA) concept, which was new to most of them. Although this concept centers on people living with HIV/AIDS, the importance of active involvement applies to other marginalized groups such as IDUs.

Small Grants

Since drug treatment and HIV service providers were not linked, part of the core package design was to help IDU groups establish HIV prevention and support education by obtaining funding for trainings in their rehabilitation centers. Six drug rehabilitation centers in four regions of Nepal received small grants to adapt the draft HIV leadership curriculum developed by RN to train their staff and clients, especially those who had recently stopped using drugs. One center was chosen per regional district, in addition to the only drug rehabilitation center in the country for women. The following centers received grants: Serene Foundation (Pokhara), Richmond Fellowship and Richmond Women’s Center (Kathmandu), Nepal Youth (Kathmandu), KYC (Dharan), and Sahara (Butwol). The centers focused on support for “newly clean” IDUs by increasing their understanding of HIV transmission and prevention, the dynamics of addiction, how to stay off drugs, stigma and discrimination, and misconceptions of drug use and HIV/AIDS. Eleven to 27 participants in each center attended sessions several times a week for a month or more. In total, 123 (112 men and 11 women) IDUs were trained through the small grants. Although the grants were in place for only 3–5 months, most of the centers continue to use the training and have incorporated it into their drug rehabilitation program. Furthermore, participants from one center have since used their increased knowledge to conduct awareness-raising activities in schools and the community.

Advocacy for Change Workshop

In March 2004, RN held an IDU training workshop called Advocacy for Change, with 21 IDUs attending from across Nepal. All participants had taken part in either the initial leadership training or the replication training, and all AG members were present. The workshop received a high level of support with opening speakers from USAID, NCASC, and MOHA. Mr. Ram Prasad Shrestha’s (ex-Director of NCASC) words of support included, “To bring about change in the risk behaviors of IDUs, IDUs must themselves be involved.”

Nepal Core Package Final Report 14 “The method of punishing people who are using drugs is not a permanent solution, because drug users should be treated as human beings with respect and protection of their rights. The maintenance of all people’s human rights is important for Nepal. Thus, if there is any kind of mistake or difficulty for the IDUs in our laws then we must work to reform or renegotiate such laws.” —Mr. Kumar Poudyal, Joint Secretary of the Ministry of Home Affairs

The workshop’s objectives were to help participants

 Understand basic legal rights and the planned advocacy for changes in laws related to IDUs and HIV in Nepal  Assess the strengths, challenges, benefits, and risks of IDUs as advocates  Become familiar with the steps in an advocacy process, which are to  Prepare a six-month plan for advocacy

Follow-up Advocacy Workshop. A month after the initial advocacy workshop, the same participants attended a two-day workshop to revise and finalize their advocacy action plans. AG members facilitated the workshop with assistance from a consultant. They looked at synthesizing regional plans aimed at sensitizing communities and identified priority activities with achievable implementation plans and specific steps.

The group decided that formulating a nationwide plan with the same objectives and similar activities—to carry out during similar timeframes across regions—would have the maximum impact on community attitudes and policymaking. The group identified three main advocacy objectives:

 Desensitize the community on existing stigma and discrimination against IDUs and PLHAs, and raise awareness of facts on drug-related issues and HIV/AIDS;  Advocate to key players for the allocation of funds to provide treatment, care, and support for IDUs and PLHAs; and  Build a two-way support system/network among the community and service providers that will work to provide affordable and available treatment, including care and support for male and female IDUs.

To meet the above objectives, participants engaged in the following advocacy activities:

 Interaction programs/meetings with community members/leaders and service providers;  School awareness programs;  Press conferences/press releases;  Regional joint committees among longstanding and more recent IDU leaders, service providers, police, and community stakeholders to determine activities

Nepal Core Package Final Report 15 (rallies, press conferences, meetings, talk shows, etc.) based on community needs;  Orientation programs for recovered IDUs so they can participate in joint committees and in creating advocacy action plan activities; and  Talk programs.

Nepal Core Package Final Report 16 V. Recovering Nepal’s Achievements

Nepal’s First IDU Network United IDUs and Increased Their Leadership Capacity

Nepal’s first IDU network. The Nepal core package has fostered a long-lasting network of IDUs. Before RN, IDUs did not have a central place to meet or a group to lead them. RN filled this gap, uniting IDUs and increasing the knowledge of drug use and the presence of IDUs in society. Its capacity-building work with IDUs spawned a movement that institutionalized RN and IDU advocacy within the country. In May 2005, RN was formally registered with the chief district office and social welfare council of His Majesty’s Government of Nepal (HMG) and received a certificate as proof of registration. RN drafted bylaws and a structure, and the advisory group was renamed the executive committee. RN’s mission is to “advocate for the rights of drug users so that there is affordable and available treatment for drug users and PLHAs of Nepal.” Currently, there are approximately 3,000 recovering drug users in Nepal. Most of the ex- users and some active current IDUs are directly and indirectly involved in this network. Since May 2004, RN has served as a strong network of committed people who are helping to address stigma and discrimination, raise voices to promote basic rights, advocate for policy change, and increase quality access to affordable and comprehensive treatment care for drug users and PLHAs. As of September 2005, Recovering Nepal had 64 members, including 11 executive board members, 50 regional advisory board members, and three advisory members. There is also an “informal” regional group with 14 members—in a region of Nepal that is difficult to access due to the political situation. Currently, RN has four paid staff members, along with a consultant hired to facilitate the drafting of operational guidelines.

After every AG meeting we would hold another meeting without the POLICY staff. It is a very diverse group—all castes, ethnic groups, religions, and educational levels. We all used to hate each other’s guts. This project has united us. This is a real fellowship! —RN co-coordinator

Increasing IDU leadership capacity. RN’s series of workshops formed a team of IDUs who are aware of their rights and eager to share their knowledge. Additional workshops facilitated through small grants and advocacy efforts were successful in assisting hundreds of IDUs in increasing leadership skills, improving HIV knowledge, and undertaking policy dialogue (see Table 2). With this number of training sessions and participants, RN has brought IDU and HIV issues to the forefront of the policy arena.

Nepal Core Package Final Report 17 Table 2. Training Results

Date Topic Days Sessions Participants Area July 2003 National 3 11 50 9 districts consultation February Leadership 5 12 38 8 districts 2004 March– Regional 1 19 350 5 regions April 2004 leadership March 2004 Advocacy 4 14 21 -- April– Drug rehab 10 12–14 123 4 districts October leadership 2004

RN Successfully Used the Media to Raise Awareness Advocacy in the mainstream media. The Nepali media was a successful vehicle for conveying advocacy messages. Nepal’s media industry has grown significantly over the last few years, resulting in hundreds of newspapers and more than 30 FM radio stations. RN took advantage of these new outlets, engaging the media in awareness raising and public dialogue on IDU rights and issues. RN’s good relations with newspapers, radio, and TV stations resulted in transforming media coverage of drug users from promoting negative stereotypes and attitudes to focusing on the key contributions that addressing IDU issues and involving IDUs in designing effective responses could play in reducing HIV vulnerability. This coverage initiated a widescale effort to raise awareness of risks and prevention. RN also worked with journalists through press conferences to highlight and disseminate information on HIV/AIDS prevention and the current situation of recovering drug users and PLHAs in society. Newspaper Headlines from Nepal:

 The HIV/AIDS problem is bigger than the Maoist problem  Recovering Nepal has an interaction program in schools. In that program, the ex-drug users said that the government is ignoring HIV/AIDS due to the Maoist problem, but the HIV/AIDS problem is far bigger, so the government should consider it….  We don’t want to be called drug addicts—we should be called drug users  Ex-users are running a campaign to stop drug use. A hospice is going to be established…

The media used to present IDUs very differently. Now they are much more positive. The same is true for PLHAs. They are even broadcasting our news nationally. Quality content has also changed for the better. Also coverage. We have built up a strong relationship with the media. —AG member

Nepal Core Package Final Report 18 As a result of their advocacy activities, RN continues to receive mainstream media coverage. RN members were asked to participate in a TV debate program—two episodes were aired—discussing issues such as using a holistic approach to treatment and substitution programs and reducing stigma and discrimination among media and medical professionals. In addition, RN members participated in radio programs, including a three- month FM radio program by and for drug users, which is designed to educate other IDUs and the community about HIV and other topics. In June 2005, RN even had the opportunity to launch its own radio program, which currently airs once a week for an hour and focuses on issues facing drug users and PLHAs. Recovering Nepal communication activities. In addition to working with the mainstream media, RN has created a forum through its newsletter. One thousand copies are printed bi-monthly and are distributed in four regions to rehabilitation centers (seven in Kathmandu and five in other regions), HIV service providers, drug users, organizations that work with/for drug users and PLHAs, international NGOs, donors, and government officials. The newsletter provides information on RN and other IDU activities throughout the country and creates a sense of belonging for drug users who are not in touch with RN directly. It also increases donors’ awareness of the network and the value that comes from supporting it. The newsletter includes sections in Nepali and English, ensuring that messages reach both Nepali drug users and the many donors within and outside Nepal who do not read Nepali. Donors are an important audience because they can have a significant affect on the situation for drug users in Nepal through their support and financing of HIV and IDU programs. In July 2005, RN launched a website (www.recoveringnepal.org.np) that provides regular updates on the group and its activities. It also provides resources such as Nepal’s National HIV/AIDS Strategy and links to websites with other relevant information. By establishing a newsletter, website, and email campaigns, RN has not only created a national forum but also a global forum for fostering international collaboration. IDUs Were Involved in the Development of Policies and Programs Donor advocacy resulted in improved policies. In 2005, RN and other vulnerable groups initiated an advocacy campaign with Nepal’s Global Fund project and DFID in response to a rule that NGOs less than four years old could not apply for funds. Arguing that this process was unfair to vulnerable groups, RN and others brought this to the attention of the Global Fund Secretariat, board, and international communities through an email campaign. In response, the Chief of Operations of Global Fund wrote a letter that was distributed to the Chairman and the rest of the country coordinating mechanism (CCM). It stated that the Global Fund does not link a financial and administrative capacity in any rigid way to the operating life of the organization, and that many institutions that have recently been formed have a great ability to reach communities who need services provided under the programs they finance. Nepal’s Global Fund project and DFID changed their policies so that vulnerable groups were eligible to apply in Nepal without the restriction. HIV and AIDS (Prevention, Control, and Treatment) Bill/Ordinance, 2061. RN was invited to participate in an interactive program to review HIV/AIDS bills and laws. The participants—also including sex workers and men who have sex with men—concluded

Nepal Core Package Final Report 19 that to implement a successful program, Nepal should provide equal opportunities for participation by IDU and PLHA groups. RN made specific suggestions that were included in the Bill, which the Cabinet is currently considering for approval. The following are a few of their suggestions:

 An IDU should not be punished by police just for carrying a syringe.  Words being used to point out drug addicts and PLHAs should be banned or changed to reduce stigma and discrimination.  A policy should be established to prevent news and photos of PLHAs and drug users from being released in any media without their permission. Methadone Maintenance Program (MMP). In July 2004, when HMG announced the proposed protocol for reinstituting the MMP for IDUs, which was being developed without their participation, RN began an advocacy campaign for the inclusion of recovering IDUs in MMP policy and procedure formulation. RN felt that its involvement was crucial to designing a comprehensive, client-centered approach to methadone treatment that should include components such as counseling (abstinence, relapse prevention, family), vocational training, HIV/AIDS prevention, and access to rehabilitation services. RN researched methadone programs to inform its advocacy on how the protocol should be developed. RN then initiated a widespread email campaign and issued a letter to the director of NCASC. Following this campaign, a front-page article titled “Drug Users Ask Government to Go Easy on Methadone Use,” appeared in The Himalayan Times. As a result, RN members were invited to a meeting with the director of NCASC and a meeting with the State Minister of Health and key policymakers to discuss the implementation of the MMP. A task force was formed to review all guidelines and protocols regarding the MMP and harm reduction programs. Two RN members were included in the task force. A RN member was also included on the committee to draft the national strategy on methadone. The Methadone Maintenance Program started in five different regions through five centers on July 1, 2005. RN remains involved through social support, counseling, and program implementation. One RN member is on the Steering Committee of Substitution Therapy in Nepal, which is responsible for refining, monitoring, and supporting the ongoing program. RN is now also represented in the steering committee on risk reduction. HIV treatment, care, and support for IDUs. Currently, few donors support HIV treatment. Yet, a key RN member has shown the power of drug users despite bureaucracy and politics by creating and running a drug rehabilitative program specifically for HIV- positive male drug users, which includes ARVs and other HIV treatments contributed by small donors. In addition, RN members from Pokahara raised funds and were able to open an HIV hospice center in Pokhara. Lastly, the RN regional board is working with the government to designate Pokhara as a focal point for ARV distribution.

Nepal Core Package Final Report 20 Awareness-raising Events Led to Policy and Donor Dialogue The number of drug users is projected to be at least 50,000. Currently, there are 30 drug treatment centers that can provide services for up to 2,300 drug users a year. This means that only around 4.5 percent of the total drug users have access to drug treatment services. However, since drug treatment centers are run by nongovernment sectors and without external funding support, they are relatively expensive. On average, a drug user spends around Nepali rupees (NRs.) 3,000 a month, whereas the average cost for drug rehabilitation is NRs. 5,000. The majority of drug users cannot afford treatment. Moreover, lack of support and follow-up services leads to high relapse rates. Thus, drug treatment services should be scaled up immediately. If treatment, care, and support services can be provided in an affordable and planned way, drug users will have improved chances of recovery.

World Anti-Drugs Day. In 2004, there were sensitization activities, training events, press releases, and media coverage in every region. More than 19 articles in national and local newspapers were written as a result of IDU involvement. In 2005, RN worked with the MOHA, local support groups, and rehabilitation centers to coordinate an event and program for World Anti-Drugs Day. RN requested that rehabilitation centers provide free drug rehabilitation for clients who seek treatment on that day, and initiated a signature campaign to pressure the government and donors for affordable treatment, care, and support for the IDU community. RN committed itself to collecting signatures of recovering drug users from all over Nepal for banners reading “Comprehensive program for drug users now!” and presented these banners and an RN position paper to UN representatives on World Anti-Drugs Day.

World Anti-Drugs Day, 2005

Nepal Core Package Final Report 21 RN was successful in garnering media and government attention on World Anti-Drugs Day, June 26, 2005. As part of the event, more than 70 drug users from Kathmandu held a demonstration on June 27 for five hours and hung the banners with signatures in front of the UN office. Activists carrying large placards with slogans stood side by side at the entrance of the building. Nepal television aired interviews with RN members on national news. Because of their efforts, RN members were invited inside for a meeting with representatives from UNAIDS and UNICEF; it lasted over 45 minutes and resulted in the UN representatives agreeing to facilitate a comprehensive program for drug users and to review a proposal from RN. As drug user groups were previously excluded from program formulation, the outcomes of this event were substantial accomplishments.

Strategic Relationships Were Developed Between Governments and IDUs

IDU and government collaboration. RN’s status as a visible advocacy network of IDUs positioned it well for collaborative work. RN was represented on the national committee to draft the methadone strategy and on several government and/or donor steering committees. For example, an RN member attended a workshop to formulate a national operational plan for 2005/6. RN also assisted with a Prevention of Mother-to-Child workshop and jointly sponsored a drug awareness program with the MOHP and the Gurkha Army Ex-Servicemen’s Organization.

Sustainability. As an independent NGO, Recovering Nepal is obtaining other donor funds. Currently, they have a verbal agreement with a few donors and have received funds totaling approximately $20,000 for the 2005 First National Conference on Drug Abuse and Drug-Related HIV, including support from the MOHA in sponsoring the conference banner.

RN Achievements Resulted in Global Attention

International conferences. In publicizing its work internationally, RN has helped foster global collaboration. In 2004, an RN poster abstract was accepted, and the network was asked to present at a satellite session at the International AIDS Conference in Bangkok. RN presented its history and progress and shared lessons learned in an effort to inspire others to initiate similar projects. RN also introduced itself at the International Harm Reduction Conference in Belfast (March 2005) and as a result of its participation, an RN representative was selected as an Asia representative in the International Network of Users Group and now serves on the international steering committee for the 2007 International Harm Reduction Conference to be held in Vancouver.

To further strengthen the network, RN is holding the first National Conference of IDUs and drug users in Nepal in November 2005. The conference will encourage greater involvement of drug users, other affected communities, and key stakeholders in presenting achievements and activities related to prevention, care, and treatment for drug addiction, particularly in relation to HIV. The conference will provide an opportunity to increase the understanding of Nepal’s HIV/AIDS epidemic and drug-related issues, share lessons learned, and gain insights applicable to future efforts. Participants will include IDU leaders, service providers for drug users and PLHAs, donors, government leaders and police, families of drug users, and the media. RN has successfully brought together

Nepal Core Package Final Report 22 various government agencies, donors, and cooperating agencies to serve on an advisory committee for the conference.

Nepal Core Package Final Report 23 VI. Implementation Challenges

As with any project, there were challenges in implementing the core package activities. These challenges were largely related to its focus—IDUs—in addition to the country context. Negotiating these challenges has been important to RN’s growth process and its members’ capacity as advocates. The POLICY Project learned several lessons and, as a result, is better equipped to work with different vulnerable populations. Both RN and POLICY are overcoming difficulties as the project continues to expand.

Relapsing

The issue of relapse is a contentious one and affected this project from the beginning. Problems were common and included conflict between current and ex-users related to ownership and participation. Ex-users often feel threatened and vulnerable being around current users. At the same time, users who have relapsed often feel unable to reach out and confide in or ask for help from their peers who are clean for fear of being ostracized. It is not unusual for support from an ex- using peer group to suddenly disappear, even if the person in question relapses only once. During the leadership training and for several weeks after, this issue emerged, causing much friction and conflict among RN members and between RN members and POLICY staff.

Both RN project coordinators relapsed after they began their work. Due to disagreements over the coordinators’ use of drugs, a contract was drawn up detailing what was expected of the coordinators and the behavior that should be adhered to, in the hope that this would clarify expectations and establish ground rules for the use of drugs on the job. Unfortunately, the contract was not successful, and the coordinators resigned from their positions. However, they have continued to work with RN in other ways.

Current drug users vs. recovering users. Related to drug relapse, there was an ongoing debate on whether to work with current drug users or recovering users. The original project concept included both ex-IDUs and current IDUs. However, the coordinators’ relapses sparked a discussion around this issue. The AG decided to focus on developing skills as ex-IDUs, along with others in recovery. Under this premise, once they were comfortable with their leadership and advocacy skills, they would feel ready to work with current users. Thus, ex-IDUs maintained leadership of the project. This discussion signified an important turning point in the project. It was an ongoing dilemma and point of contention within the AG, and even now, the group continues to grapple with when and how to involve current users.

I see the recovering and using issue as the biggest one we have to face. A lot of mistakes were made, but now we have a broader understanding of what can be done.

Nepal Core Package Final Report 24 It’s an evolving understanding. We are still trying to work it out. —AG member Political Climate

The political environment created obstacles. Throughout the project’s life, Nepal endured an unstable political environment. During this time, His Majesty the King fired the government and declared a state of emergency. Despite the difficult political situation, RN participants were eager to take part in this project. For example, on the day of the National Leadership Training, a five-day strike called by the Maoist Party began. Even though the nationwide strike halted transportation and the government and donor speakers were not able to attend, all of the invited participants attended the training.

However, despite this enthusiasm, some of RN’s activities were indeed affected by the political climate. At different points, email and phones were shut down in the country. As a result, executive members were out of contact for weeks. In addition, regional action plans had to be scaled back. Organizers realized that it would not be possible to implement all seven regional consultation meetings due to civil unrest in particular regions. Instead, only four were held, along with three regional advisory meetings. It continues to be a challenge for the Executive Committee members outside of Kathmandu to travel from their regions and meet as a group.

Relationships with government and the lack of coordination. RN’s ability to develop and maintain good working relations with the two main bodies responsible for drug and HIV issues—MOHP and MOHA—has been hampered by the almost monthly change in government staff. During the last two years of the project, POLICY and the IDUs worked with 6–8 different director generals of the ministries. Working relationships have been further hampered because the two ministries have differing approaches to the issue of drug use, resulting in different policies and varying attitudes toward and levels of support for RN’s activities. AG members have had more success at forming and sustaining working relations with regional government representatives, which have stayed in place for a longer period.

The leadership at the health ministry has changed yet again, so there are questions regarding consistency and commitment. Sustainability requires a high level of commitment at a high level. In Nepal, there is very little institutional memory. So things are very dependent on the person and if they change then things change, too. —POLICY/Nepal staff

There is also conflict between the Ministry of Health and the Ministry of Home affairs. The agenda of the health ministry is health, but that of the home affairs ministry is law and order. We are the bridge between the two. The biggest problem is not at a higher level, but at the

Nepal Core Package Final Report 25 community level. We need to convince the community of the benefits of our approach. —AG and EC member Women’s involvement in Recovering Nepal. In Nepal, as in many countries, negative and discriminatory attitudes toward women are embedded in the culture. Female drug users face double discrimination in being women as well as drug users. This is compounded by the associated links between drug use, prostitution, and HIV. It is likely that if a woman is a member of any of these three groups, it is assumed that she belongs to the other two groups as well and is treated accordingly. As a result, female drug users are not as likely to disclose their drug use. If they do, their chances of gaining respect among the male members of their peer group, let alone among those in positions of authority, are slim.

While there is a common assumption that all IDUs are male, RN knew that women needed to be included in the project. In the first national consultation meeting in July 2003, eight women were invited but only two attended because of a fear of disclosing their drug use, even to male IDUs. From the beginning, IDUs stated that they wanted “gender balance.” They recruited a woman as one of the coordinators, acknowledging that a woman’s perspective and experiences were crucial to engaging women. However, the female coordinator resigned due to relapse, and RN did not find a woman to replace her. All the other women who became involved also relapsed. Lacking a female IDU role model, RN struggled with reaching and involving women in their work. RN’s workshops did not draw many female participants. In an effort to change this, women-only sessions were held, but these sessions did not enable women to serve as role models within the network.

RN agreed that involving women should have been seen as a priority, using specific strategies to facilitate their involvement. The few women who did participate in sessions pointed out that female IDUs have different needs from men. One IDU pointed out that there is only one women’s rehabilitation center in Nepal. She said that women are not supported by parents as much as men and that their responsibilities prevent them from seeking help from rehabilitations centers. In addition, there are few opportunities for women after rehab. It is clear that is much harder for women IDUs to remain off drugs due to a lack of support and services and extreme stigma and discrimination, even within the male IDU community. RN has made it a priority objective to reach active female IDUs for the upcoming year.

We have not found so many women IDUs so far. What methodology is there to identify them? The main problem is access to this group. They are culturally and socially stigmatized. If we have the network of drug users they may be able to help with access, as long as they can reach them. There is stigma against both groups – it’s a question of magnitude with men and women. —National Centre for AIDS and STD Control

Nepal Core Package Final Report 26 Capacity Building Capacity of POLICY staff. Working with vulnerable populations like IDUs requires a certain set of skills and understanding of experiences. Staff need consistent and ongoing mentorship, as capacity building cannot be done with just training alone. Lacking extensive experience working with drug users, POLICY staff had to adjust their expectations and rethink the type of technical assistance (TA) needed to successfully lead the project. During this time of adjustment, staff and IDUs learned how to interact with one another in a productive manner, without stereotypes. In addition, POLICY/DC and POLICY/Nepal staff defined their roles and responsibilities for the project in providing TA. Capacity of IDUs. IDUs also had to develop leadership skills and confidence in their abilities. Often, even though many drug users have informally picked up impressive life skills, many do not recognize these skills or feel inadequate when dealing with professionals who have the institutional qualifications they lack. Many drug users have missed out on traditional routes through the educational system and lack the requisite qualifications that are usually required to obtain employment in the professional arena. As a result, IDU capacity to work on a donor-funded project was low. Thus, English, computer, reporting, budgeting and accounting, and proposal development and writing skills needed to be developed. The lack of English language ability and computer skills was a hindrance in reporting, and the compilation process was difficult due to inadequate financial reporting. All AG members should have received financial training to enable easier auditing. The language barrier resulted in a recommendation that priority should be given to English speakers during the selection of AG members. While RN organizers and members did an impressive job of improving their capabilities, they could have benefited from a year of strengthening all the above skills, which was not possible due to the short duration of the project. Stigma and discrimination in IDU treatment. According to RN members and POLICY/Nepal staff, stigma and discrimination led to problematic relationships between RN members and health professionals in the HIV service and drug fields. RN had to convince rehabilitation centers to allow leadership programs, as some service providers believed that IDUs could not hold jobs and should not have leadership positions. Often, professionals who talk about “empowerment” become challenged when “empowerment” actually occurs and they are questioned about some of their activities and working practices. RN worked at treading the fine line between challenging and advocating for change and maintaining relations that are necessary to operate in the Nepali context.

My boss introduced me to the project, but now he doesn’t like it. Non-IDUs see Recovering Nepal getting good results. The professionals used to get good results and be the stars in the field – the pioneers. Now they feel they are working themselves out of jobs if they involve us too meaningfully. —AG member.

Nepal Core Package Final Report 27 Nepal Core Package Final Report 28 VII. Future Perspectives on Recovering Nepal

Where Is Recovering Nepal Now?

RN has demonstrated that drug users, if given the opportunity and assistance, can engage meaningfully in policy and program development and implementation. The POLICY Project’s facilitation of IDU capacity building fostered a thriving support and advocacy network for IDUs. This network will have a long-lasting impact, as RN was officially registered in May 2005, outliving the core package. RN remains motivated and focused on expanding its work and reaching a wider audience by increasing regional representation from all areas of Nepal, even those hard to reach due to civil unrest. Regional advisory groups are being established, along with guidelines on the selection and roles of members. Thus far, this process has resulted in 42 advisory members.

The focus will be to bring in those who are not yet involved. It will also include broader regions, with more reach. In this way we hope regional problems can be identified by regional people, which will result in overall greater involvement of drug users in Nepal. We will be doing training for proposal writing and developing new AAPs. We will also run report writing training. Recovering Nepal won’t wait for donors all the time and will mobilize local resources. We will also concentrate on volunteer mobilization. —AG member

RN is also working with others to teach them what they have learned. In this way, RN functions as a resource for other organizations, including those just starting to be formed. An RN co-coordinator said, “We can help show others how to do reports, etc. We ‘learn by practice.’ We are not ‘professionals,’ that is we don’t have qualifications, but we learn on the job.”

Areas to address to fully achieve the stated goals. As RN continues to grow, it has to address many remaining areas to fully achieve its goals. Key areas include focusing on increasing female drug user leadership and involvement and ways to work more closely with harm reduction services.

We need to adapt services for women. I learned from this project that there are other options. We cannot meet as women—we are not unified as IDU women. IDU women have their own responsibilities and cannot meet. I am gathering ideas on how to take this forward.

Nepal Core Package Final Report 29 —Former female coordinator

What Will It Take to Replicate Recovering Nepal’s Success?

RN has been in the forefront advocating for increased attention and resources for programs for drug users. POLICY’s support in the last two years has played a crucial role in improving the communication, coordination, and advocacy skills among the network members. This core package helped Nepali IDUs collaborate, identify issues, and create a platform for a network of drug users. It also proved that a network of IDUs can play a vital role in enhancing the quality of life of drug users through meaningful involvement in policymaking and program design and implementation. Part of the project’s purpose was to create a model to involve IDUs in the policy and program environment that can be adapted and used by other countries addressing IDUs and vulnerable populations. In following this as a model, there are many considerations to be made.

Ownership, roles, and responsibilities. To successfully implement a similar undertaking, project funders and implementers need to be clear on each other’s roles and responsibilities. Both AG members and POLICY Nepal staff identified this as a challenge, citing it as an important consideration for any future replication of the project. Project implementers need to give up ownership to allow the “by and for” approach to work. This entails trusting and working with groups to develop skills and plan, design, and implement programs and activities to suit their needs.

Skills of project staff. Those who provide TA should either be experienced in specifically working with drug users, especially IDUs. In addition, staff providing TA need to examine their own stereotypes and levels of stigma and discrimination when interacting with IDUs. Also, they must be prepared to deal with unique IDU issues, such as relapse and the difficulty of involving women. Since IDUs may not have project management skills and might have limited educational backgrounds, TA needs to be available at the local or field level, where assistance may be greater than estimated.

Skills and capacity building for IDUs. Capacity building was crucial to RN’s success, as the initial IDU capacity-building effort resulted in the formation of the AG. Future projects should include preparation time to work with IDUs to develop similar skills. Ongoing mentorship and support needs to be built into the program design. RN members have reported increased confidence in giving presentations, organizing training materials and meetings, preparing curriculum, understanding advocacy issues and how to implement them, coordinating and facilitating activities, writing proposals and reports, and providing general leadership. With this increased confidence, members became increasingly determined to use their skills to advocate for IDU rights and issues within Nepal. This capacity also ensured that the “by and for” approach was implemented as RN members became fully equipped to run the network. RN was successful because those involved were invested in the project, as leaders and role models in their own communities; IDUs recognized the value in training and working with each other to enact change.

Nepal Core Package Final Report 30 Even if we don’t have master’s degrees, we can learn from those who have the skills and we have our own skills that education alone does not bring. In this project, some can’t read or write English and they feel inferior, but they can mobilize and be leaders. In the future we need to acknowledge ALL different skills and encourage different people to specialize within the group, depending on their particular skills (e.g., some people are great speakers, but others are good with proposal writing and others with organizing behind the scenes). —RN Co-coordinator

Collaboration at multiple levels. A spirit of collaboration needs to be fostered in advocacy campaigns and in efforts to form a network beyond IDUs. Including government agencies and donors in the network ensures the likelihood of policy reform. RN achieved this through its initial workshops, after which government participants became invested in the network and the concerns and needs of IDUs.

To build the IDU leadership and advocacy skills of a greater number of people, IDUs need to work with drug treatment facilities to run training sessions in the facilities as part of their programs. This is how RN expanded leadership—by health providers suggesting participants for workshops and by running their own workshops at their facilities. In reaching a wider audience, IDU involvement is increasing in various regions of Nepal— as evinced by the formation of regional groups.

A Final Word from Recovering Nepal

We hope this report has managed to convey some of the flavor, passion, and commitment that those of us who were involved in the project have experienced. Recovering Nepal is not just about recovering from using drugs; it’s about recovering our respect, our dignity, our human rights, our health, our well-being, our confidence, and our rightful place in a stigma-free society as drug users. Our vision is inclusive of current or ex-users—for there is a fine line between using today and being clean tomorrow or being clean today and using tomorrow. In the past, we have all been judged harshly by others and have learned through the project that it is not our place to judge those who have been less successful than ourselves in becoming or staying clean. As we have learned, this is even more of a challenge for the many women drug users throughout the Kingdom of Nepal, who do not have access to the majority of the services that exist to help with recovery, and we are committed to continuing our advocacy work for the availability of a whole range of services for all drug users in our society, regardless of their gender.

Nepal Core Package Final Report 31 References

Burrows, D., S. Panda, and N. Crofts. 2001. “HIV/AIDS Prevention among Injecting Drug Users in Katmandu Valley.” Report for the Center for Harm Reduction. Melbourne, Australia.

FHI and Centre for Research on Environment, Health, and Population Activities (CREHPA). 2003. Injecting and Sexual Behavior of Injecting Drug Users in Kathmandu Valley. Unpublished.

FHI and National Centre for AIDS and STD Control (NCASC), Ministry of Health, His Majesty’s Government of Nepal. 2004. National Estimates of Adult HIV Infections Nepal 2003. Kathmandu: Family Health International.

Government of Nepal. 2002. “Nepal’s National HIV/AIDS Strategy. Final Draft. June 2002.” Kathmandu.

Karki, B.B. 2000. Rapid Assessment Among Drug Users in Nepal. AIDS Watch 5(20): 3–5.

National Centre for AIDS and STD Control (NCASC). 2004. Cumulative HIV/AIDS Situation of Nepal. Monthly Reports on Cumulative HIV/AIDS Statistics. Kathmandu: NCASC, p.4

New Era/SACTS and FHI. 2002. Behavioural and Sero-Prevalence Study Among IDUs in Kathmandu. Unpublished.

New Era/SACTS and FHI. 2003a. Behavioural and Sero-Prevalence Survey Among IDUs in Eastern Terai Districts (Jhapa, Morang, and Sunsari). Unpublished.

New Era/SACTS and FHI. 2003b. Behavioural and Sero-Prevalence Study Among IDUs in Pokhara. Unpublished.

Reid, G. and G. Costigan. 2002. “Revisiting ‘The Hidden Epidemic’: A Situational Assessment of Drug Use in Asia in the Context of HIV/AIDS.” Melbourne: Burnet Institute, The Center for Harm Reduction.

Saidel, T., D. Des Jarlais, W. Peerapatanapokin, J. Dorabjee, S. Singh, and T. Brown. 2003. “Potential Impact of HIV among IDUs on Heterosexual Transmission in Asian Settings: Scenarios from the Asian Epidemic Model.” International Journal of Drug Policy 14: 63–74.

Shrestha, Dr. Dhruva M. 1999. Personal communication with Recovering Nepal about survey in Mental Hospital Lalitpur.

Nepal Core Package Final Report 32 UNAIDS and UNDCP. 2000. “Drug Use and HIV Vulnerability: Policy Research Study in Asia.” Bangkok: UNAIDS and UNDP.

UNAIDS, UNICEF, and WHO. 2004. Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections: Nepal, 2004 Update. Geneva: UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance.

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