1. Government funds allocated for MSMs HIV/AIDS US$ 146,657 [MoHP] 1. Kathmandu 33.6%
2. National Composite Policy Index Migrants 93% Annex 2 Young People 82.5% Additional (who know at least 3 prevention ways) Development partners committed US$ 14.5 million for budget of 6. % of female sex workers reporting the US$ 23.6 million 2005-6 use of a condom with their most recent client Kathmandu 74% 3. % of (most-at-risk populations) who 22 Terai hwy districts 53.3% received HIV testing in the last month and Pokhara 64.5% who know the results . (Source: IBBS study- NCASC / New Era / FSWs 3.1% SACTS / USAID/FHI, 2003, 2004) IDUs 5.2 % Migrants 0.03% 7. % of men reporting the use of a condom MSMs 0.04% the last time they had anal sex with a male Others (FSWs clients) 0.21% partner (Source: FHI VCT centres programme Kathmandu 63.4% report) (Source: IBBS study- NCASC / CREHPA SACTS / USAID/FHI, 2004) 4. % (most-at-risk populations) reached by prevention Programmes 8. % of IDUs who have adopted FSWs 35.2% behaviours that reduce transmission of IDUs 8.6% HIV, i.e., who both avoid using non-sterile Migrants 0.04% injecting equipment and use condoms, in MSMs 5.4% the last month
Kathmandu 42% 5. % of (most-at-risk population(s)) who Pokhara 43.9% both correctly identify ways of preventing Eastern Terai 26.5% the sexual transmission of HIV and who Western Terai 28.8% reject major misconceptions about HIV (Source: NCASC/USAID/FHI IBBS 2005) transmission . FSWs 9. % of (most-at-risk population(s)) who Kathmandu 6.8% are HIV infected ( for capital city ). 22 Terai hwy districts 22.8% FSWs 2% Pokhara 10.4% IDUs 51.6% (who know ABC prevention ways) MSM 3.9% (Source: IBBS study-NCASC/New Others (spouses of MAR) 12.4% Era/SACTS/USAID/FHI, 2003, 2004) (Source: IBBS study- NCASC / New Era / SACTS / USAID/FHI 2004, 2005) IDUs Kathmandu 53% Eastern Terai 50.1% Western Terai 39.7% Pokhara 56.7% (Source: IBBS study-NCASC/New Era/SACTS/USAID/FHI, 2005) 2 Source: IBBS study-NCASC / CREHPA / SACTS / USAID/FHI, 2004 1 Denominators used – National size estimates 3 Source: Global Fund/New ERA survey 2005 in all cases (NCASC/FHI, 2005) 4 Source: UNAIDS/New ERA survey 2005
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In a special session of United Nations General Assembly (UNGASS) on HIV/AIDS held in June 2001, head of states of 189 countries made special commitments to combat the HIV/AIDS epidemic at a global, regional and national level. As a signatory, the Kingdom of 1. Leadership at all levels Nepal realises that these 2. Prevention a mainstay of response commitments require country- 3. Care, support and treatment specific planning to translate into fundamental elements actions. 4. Human rights have to be realised to reduce HIV/AIDS The country is experiencing a 5. Reducing vulnerability should be give which is priority spreading rapidly amongst its most- 6. Orphaned and affected children need at-risk group and its response special assistance focuses on UNGASS’s core 7. Alleviating social and econo mic impact indicators for concentrated/low- through sustainable development prevalence epidemics. 8. Research and development for cures and effective responses The following 9. Conflict and disasters-affected regions highlight the key focus areas of 10. Resources are required to meet the Nepal’s response to its concentrated challenge epidemic: 11. Follow-up and monitoring progress is essential for maintaining momentum 1. Amount of national funds disbursed by governments in low- and middle-income countries
2. National Composite Policy Index
3. Percentage (most-at-risk populations) who received HIV testing in the last 12 months and who know the results
4. Percentage (most-at-risk populations) reached by prevention programmes
5. Percentage of most-at-risk populations who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission
6. Percentage of female and male sex workers reporting the use of a condom with their most recent client
7. Percentage of men reporting the use of a condom the last time they had anal sex with a male partner
8. Percentage of injecting drug users who have adopted behaviours that reduce transmission of HIV
9. Percentage of most-at-risk populations who are HIV infected
These core indicators and the related areas of commitment are central to Nepal’s progress in addressing HIV and AIDS and will be referred to throughout this report.
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The HIV/AIDS situation in the Kingdom of Nepal has been categorised as a . This is because HIV prevalence estimates for the general population are around 0.7% while they may be as high as 52% amongst some of the groups identified as being most-at-risk. In this country context, most-at-risk groups include intravenous drug users, female sex workers and migrants.
The are further exacerbated by: • Geographic and ethnic diversity • Its landlocked location between India and China • Poverty, inequality and underdevelopment • Civil conflict and political instability • Varied levels of knowledge about HIV transmission among most-at-risk groups and young people • Insufficient risk reduction behaviours among most-at-risk groups and young people
These factors as well as the limited coverage and utilisation of HIV-related health services have also made a challenging task. Indications are that the epidemic will increase without effective interventions, and the Millenium Development Goal 6 and its target of halting and beginning to reverse the spread of HIV/AIDS by 2015 will not be achieved.
The first cases of AIDS were reported in Nepal in 1988. The epidemic that emerged has largely been transmitted through injecting drug use and unprotected sexual contact. The most recent prevalence estimates for Nepal indicate a – based on seroprevalence studies of ANC (0.7%, 2005) and blood donors (0.29%, Kathmandu, 2005). As of December 2005, the Ministry of Health (MoHP) ••• Predominant modes of transmission are injecting drug use has reported 959 and unprotected sexual contact, mainly heterosexual but cases of AIDS increasing among men who have sex with men (MSM) and 5,828 HIV ••• Current prevalence of HIV/AIDS among urban-based MSM infections. Given is 4%. the existing ••• Highest rates of HIV have been identified in injecting drug medical and users (IDUs) public health ••• Data indicates that risk behaviours are widespread among reporting system sex workers (FSWs), their clients, injecting drug users, in Nepal and the labour migrants and youth/young people. limitations of the ••• Current estimated HIV infection rate is 0.3 % of the adult national population between the ages of 15 - 49. HIV/AIDS ••• There was evidence of an explosive increase in the surveillance number of infections from 1996, which now may have system, it is very started to stabilize likely that the ••• Increasing levels of Sexually Transmitted Diseases (STDs) actual number of reported cases is many times higher.
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Nonetheless, Nepal’s HIV epidemic is thought to be largely isolated to these groups identified as most-at-risk – consistent with a concentrated epidemic.
The low prevalence currently estimated among the general population is understood to be masking an including, FSWs (2% in Kathmandu, SACTS, 2005), IDUs (51.6% nationwide and 58% in the Kathmandu Valley, NCASC/USAID/FHI, New Era, 2005) and labour migrants returning from Mumbai (India) (7.7%, NCASC/USAID/FHI, New Era, 2002).
HIV infection has been noted among men and women and in rural and urban areas. There are however (3 men for every woman, NCASC, 2006) and more cases reported in the . Accurate estimates of the rural-urban ratios are yet to be determined, but prevalence rates for rural districts are varied.
Estimated number of adults & children living with 68,600 2005 HIV/AIDS Estimated adult and child mortality due to HIV/AIDS 3,800 2005
Reported HIV cases 5828 Dec 2005 Reported AIDS Cases 959 Dec 2005 Source: NCASC, 2005
(a) Prevalence data among most-at-risk populations
Female Sex Workers (FSWs) Prevalence data among female sex workers are differentiated by districts, rather than nationally. This approach is useful in identifying critical districts and in prioritizing programme resources.
• In an FHI study conducted in 2004, among the 200 street-based FSWs and 200 establishment-based FSWs in Kathmandu, 2% of both types of sex workers were found to be HIV positive. The percentage of street-based FSWs who have HIV or syphilis infection is 18%, whereas the rate for establishment-based FSWs is 8% (FHI 2005). The total estimated number of FSWs in the Kathmandu valley is between 7,000 and 8,000. • Teenaged girls are entering into commercial sex work, with about 30% of FSWs younger than 20 years of age. However, nearly 40% of sex workers are married, among whom less than 20% use condoms with their spouses. • An estimated 50% of Nepalese sex workers in Mumbai brothels are HIV positive (FHI 2004).
Injecting Drug Users (IDUs) • Among all IDUs in Nepal (estimated at 19,850), HIV prevalence varied by location; 22% are HIV positive in Pokhara where as the prevalence rates in
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Morang, Sunsari and Jhapa districts are 52%, 33% and 8% respectively (FHI 2005). Among IDUs in Kathmandu (estimated at 5-6,500) the rate has significantly decreased from 68% to around 52%. In addition, a survey of 300 female sex workers in Kathmandu (FHI, 2000) revealed that 15 self-reported ever having injected drugs, representing 5% of the total sample. Of these 15 women, 11 were found to be HIV positive.
• A 2005 study by FHI, indicated that IDUs are concentrated in many locations within Morang, Sunsari and Jhapa districts and have access to a wide range of drugs. They often use the same needle a number of times and cleaning practices are very poor. Often they engage in risky sexual behaviours including multiple sex partners and injecting partners. Most of the IDUs were men and 93% reported having sex with female sex partners (eastern region) and a majority reported of not using a condom. The report also showed a high level of sexual activity with low condom use with regular and non-regular partners.
Mobile populations • One of the most threatening prospects of an expanding HIV epidemic in Nepal lies with the country’s large male migrant population. An estimated 600,000-1.3 million Nepali men migrate to India alone for seasonal and long-term work, and an estimated 400,000 of these go to Mumbai, often without their families. However, there is no nationally and systematically obtained information. A very recent study (in press) by New Era, gives some updates on the status of migrants in some focus districts. Several other studies have focused on returning migrants in several districts in the Far Western region.
• From recent Voluntary Counselling and Testing (VCT) records, it was shown that nearly 23% of migrants seeking VCT services were found to be positive (FHI, 2005).
• In Doti district, one of the high migration districts, a study reported that nearly 50% of suspected PLWHAs (34 out of 71 cases), who came to the VCT centre at the Doti District Hospital in Silgadhi during June-July 2004 tested HIV positive. Almost all the positive cases (33 out of 34 cases) were widows in their twenties and thirties (CARE, 2004).
• 40% of the respondents in Achham study migrated internationally and of these 38% migrated to Mumbai only, the rest migrated to other states in India. Among the international migrants from Achham going to Mumbai 7.7% were found HIV+. This could be due to the fact that the HIV prevalence among the FSWs in Mumbai is very high.
• A recent study showed that only 12% of married migrant (total sample 1980 of whom 85% were married) respondent reported to have used condom in their last sex with their wife while 6.6% of all migrants have had sex with sex workers in last 12 months 5.
Men having sex with men (MSM) • For MSMs with an estimated population size of 7,000-20,000 in Kathmandu, a report indicated that while the condom use to their non-commercial partner is
5 Global Fund (2005), A report on baseline study for the benchmark of pre implementation situation of HIV/AIDS porgramme among migrant laborers and young people in six districts of Nepal, New Era, Kathmandu
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63%, HIV prevalence is 3.9% (2 out of 53), clearly sending a signal about the imminent threat.
(b) HIV knowledge and risk behaviour of young people in Nepal The 2005 study conducted among 2401 young male and female aged 15-29 (56% under 19 years and 64% unmarried) reported that - 95% had heard of HIV/AIDS and over 80% seem to know at least 3 correct ways to avoid HIV transmission. Knowledge level variations by geographical locations were reported. In general, knowledge on how HIV is transmitted found to be above 93 percent among all age groups. Comparing the three age groups in Table 2, the youths from 15-19 years seem to know more correct ways to avoid HIV transmission (New Era/UNAIDS 2005). Several studies have found that premarital sex is becoming more acceptable for both sexes, with 20 percent of teenagers considering it acceptable among young people 6. In another study of 800 students, over 70 percent claimed to have had sex before the age of 19 years, with only eight percent of these students were married 7.
1 2 3 4 >=5 Total 15-19 Years 3.4% 12.0% 29.8% 29.6% 25.1% 100% 20-24 5.9% 11.4% 33.4% 28.7% 20.6% 100% 25-29 5.2% 16.8% 32.9% 26.6% 18.5% 100% Total 4.7% 13.1% 31.9% 28.5% 21.8% 100%
The knowledge on the correct ways to avoid transmission of HIV appeared to have a direct attained by the respondents. Almost 100% of youths who completed secondary and lower secondary level of education identified more number of correct ways of avoiding HIV transmission followed by groups who have completed Primary (87%) and below primary (80%).
The is about 20 years old for males and 18 years old for females, predominantly in the context of marriage. This is an opportunity in the epidemiology of AIDS as a higher age at first sex would mean a slower spread of the virus.
6 UNICEF (2001). A Survey of Teenagers in Nepal for Life Skills Development and HIV/AIDS Prevention . Kathmandu: UNICEF and UNAIDS. 7 UNICEF ROSA. A Force for Change: Young People and HIV/AIDS in South Asia . Kathmandu: UNICEF Regional Office for South Asia.
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16.6 16.2 16.3 19.3 17.9 18.5 21.4 18.7 19.9 23.4 24.0 23.4 21.6 33.7 22.2 29.9 28.7 29.8 Source: UNAIDS/New Era, Behaviour, Information, Services (BIS) Survey in four urban areas in Nepal, 2005.
This profile is not applicable for one vulnerable group of young people – street children. A UNESCO/CREHPA (2005) study conducted among street children (age group 12-17) in two major locations Kathmandu (n=400) and Pokhara (n=113) revealed that while condom use at such sex was only 9 – 29%. Similarly, anal sex is reported among boys as high as 29%. While 75% of such street children have heard about HIV/AIDS, less than 20% of them have contact with an AIDS-related NGO.
An earlier study among young factory workers (M. Puri, 2002) among 550 girls and 500 boys in carpet and garment factories in the Kathmandu Valley points to vulnerabilities among young people. In the whole sample, . Among the sexually active, the mean age at first sexual intercourse was 15.8 years for boys and 15.4 years for girls. Over half the girls (51%) and over one-third of the boys (34%) had first sexual intercourse before the age of 16 years.
The Kingdom of Nepal is a highly in terms of geography, biodiversity, ethnicity, language and culture. Nepal is landlocked sharing borders with India and China and is made up of 75 districts divided into five development regions (Far-Western, Mid-Western, Western, Central and Eastern). The Himalayas cover the northern third of the country from east to west, bordering China. To their south lies a long east-west stretch of lower mountains (the hilly region) whose southern flanks flatten into the Terai, a fertile, sub-tropical plain spanning the border with India.
The increasing pressure of population growth on scarce resources such as land has . For example, provision of better education or irrigation is of limited benefit to rural populations who depend on the land for their livelihood. In Nepal, the topography, environmental degradation, poverty and economic migration are all linked and they combine with other factors to increase vulnerability to HIV/AIDS.
Nepal’s social indicators remain well below the average for the South Asia region: more than ,
7 nearly half of all children below 5 years are underweight and nearly 60% of all adults are illiterate. Additionally, women have, traditionally, a lower status than men, and gender inequality is deeply rooted. .
The which started in 1996 has now entered into a protracted phase and thousands of people have lost their lives, have fled their homes and lost their livelihoods. This instability increases vulnerability to HIV. Increasing human rights violations from both conflicting parties have drawn serious concern of both national and international communities. Amidst this scenario, National Parliament was dissolved in May 2002 and by 2005 four interim governments had been appointed by His Majesty’s the King before he assumed direct control in February 2005.
Poverty, gender inequality, low levels of education and literacy, denial, stigma and discrimination coupled with the current conflict are major contributing factors to HIV vulnerability. Female sex workers, mobile populations, injecting drug users and men having sex with men are most-at-risk populations largely due to their in the society with little access to information and services related to HIV/AIDS. Young people and children are among the vulnerable groups who are exposed to various risk factors that potentially lead to infection. Some of the factors are lack of youth friendly information and service centres, education system not able to embrace all the youth for HIV/AIDS and reproductive health information and Trafficked girls to India (par ticularly their high mobility. Increasing numbers Mumbai) are returned to Nepal when of street children who are exposed to they are tested HIV+. In absence of various exploitations including sexual other livelihood opportunity they are abuse are highly vulnerable to the likely to continue sex trade in Nepal. HIV/AIDS infection.
followed by clients of sex workers 18% and IDUs 14% (as cited in MDG report 2005). Prevalence of sexually transmitted infections was 19.4 percent for migrants, and 11 percent for their wives 8. Migrants returning from areas with high rates of HIV/AIDS prevalence such as Mumbai in India, where 70–90 percent of female sex workers are estimated to be HIV positive 9, are also displaying increased prevalence rates. One study found that nearly nine percent of migrants returning from Mumbai to Achham District were HIV positive compared to 0.7 percent of non-migrants 10 . Migrants returning from other areas of India had much lower prevalence rates. Two more groups which have not been focused on to a great extent are the Internally Limited information avai lable on sexual behaviour Displaced People (IDPs) and HIV/AIDS incidence among the labour migrants due to the conflict and the going to countries other than India (Malaysia, South Bhutanese refugees in Korea, Gulf countries) where approximately 10 Eastern Nepal where there thousand people fly every month. are over 100,000 still waiting for repatriation.
8 GFTAM prop. P.23. 2001 New Era study 9 Nepal/India Safe Migration Initiative (Reducing HIV risk among Nepali migrants to Mumbai, USAID Discussion paper, Draft Feb.2004. 10 Nepal/India Safe Migration Initiative (Reducing HIV risk among Nepali migrants to Mumbai, USAID Discussion paper, Draft Feb.2004.
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Likewise, the , (UNICEF, 2002 cited in MDG report 2005). Street children are without doubt one of the most vulnerable groups, widely exposed to various types of danger including sexual exploitation 11 ;12 . A recent study of street based children in Pokhara and Kathmandu revealed that only 20 % are reached by NGOs with HIV/AIDS education 13 .
The of the epidemic was first recognized by J.Chin (1999/2000) who estimated that in the absence of effective interventions, HIV prevalence in Nepal may, over the coming decade, increase to 1-2% of the 15-49 year old population. For Nepal this meant that 100,000-200,000 young adults would become infected and that by the end of the decade, 10,000-15,000 annual AIDS cases and deaths may be expected. This would make AIDS the leading cause of death in the 15-49 year old population.
UNAIDS/WHO estimated that the number of expected AIDS deaths in 2000 would double by 2005 to 6000. It is estimated that these AIDS deaths would increase total deaths in the 15-49 year-old age group by about 5% in 2000 and account for close to 20% of total deaths in this age group in 2005.
In 2001 a projection exercise based on available data (Sero-prevalence, BSS) was conducted by the Ministry of Health and Population and UNAIDS. Low, moderate and high infection rate scenarios were developed in order to estimate the number of people living with HIV/AIDS in Nepal (Figure 1).
Estimated number of People Living with HIV/AIDS in Nepal
180000
160000
140000
120000
100000 LOW 80000 MODERATE HIGH 60000
40000
20000
0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
11 Peace and Governance Foundation South-Asia Partnership-Nepal , Posted on 2004-10-20 ACR Weekly Newsletter Vol. 3, No. 42 12 Norwegian Refugee Council (2004). Nepal: up to 200,000 people displaced by fighting remain largely unassisted. Geneva Switzerland 13 A study on Knowledge, attitude practice and belief in the context of HIV/AIDS among out of school Street based children in Kathmandu and Pokhara (UNESCO/CREHPA November 2005)
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Antenatal clinic surveys do not seem to provide a valid channel for estimating HIV prevalence in the general population in Nepal as only about 10% of Nepali women visit antenatal clinics. The relative methods of using, ANC attendees, blood donors and family planning attendees is currently being debated by epidemiologists in an effort to find the most accurate measure of prevalence in the general population.
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The HIV and AIDS situation in Nepal encouraged its stakeholders to try to address each of the UNGASS commitments in the national response. As Nepal is experiencing a concentrated epidemic, the national response has focused on commitment areas relating to the . Thus most of Nepal’s national initiatives have focused on the first three UNGASS commitments regarding leadership, partnerships and the involvement of civil society (commitment 1), prevention (commitment 2), care and support for its most-at-risk populations (commitment 3) during the 2003-2005 reporting period. This emphasis has not been to the exclusion of other areas of the UNGASS commitment, as the national response certainly included some advances in the areas of treatment (commitment 3), monitoring and evaluation (commitments 8 & 11), financing and expenditure (commitment 10).
As a result, in commitment and action to addressing its HIV/AIDS epidemic included: • HIV/AIDS policy and strategy developments • The completion and implementation of a National Action Plan for 2005-06, with clear priorities and targets among a wide range of stakeholders • Expanded partnerships and multi-sectoral involvement in planning and coordination, including civil society • Expanded prevention activities targeting most-at-risk populations • Identification of gaps in policy and implementation • More regular surveillance with improved data quality and reporting • Increased knowledge on behaviours of most-at-risk populations, particularly young people and migrant groups.
The country has also faced numerous challenges to its response in each commitment area. were arguably: • Insufficient treatment, care and support activities (commitment 3) • Incomplete financing and expenditure (commitment 10) • Insufficient activities mitigating against the impact of conflict on HIV/AIDS (commitments 9) • Limited and isolated treatment, care and support activities (commitment 3) • Establishment and strengthening of central coordination and management mechanisms (commitment 1) • Capacity strengthening of implementing civil society partners (commitment 1) • A lack of targeted activities for certain marginalised groups, such as orphans and vulnerable children (commitment 6) • Unaddressed gaps in the legal and policy framework needed to support the strategy (commitment 1) • Insufficient central level monitoring, evaluation and follow-up systems to ensure the effectiveness of action (commitments 8 and 11)
, Nepal’s response to HIV and AIDS is led by the His Majesty’s Government’s which receives support from external development partners. Within the national health policy framework, NCASC has facilitated the development of the country’s first national HIV/AIDS policies and
11 strategies. The first of these was the Strategic Plan for HIV and AIDS in Nepal (1997- 2001) followed by the comprehensive after external review.
Amongst other things, the National HIV/AIDS Strategy makes provision for two mechanisms for the promotion of high-level political commitment and a multi-sectoral participation and coordination. The highest of these bodies is the , chaired by the Rt. Honourable Prime Minister. This body was designed as a forum for advocacy and the development of national HIV/AIDS policy and strategy and is composed of representatives of various government ministries, the private sector and civil society. Since its formation the Council has met twice by 2005. Due to frequent changes of Prime Minister and fluid political situation, subsequent meetings and policy direction as anticipated from the Council has not been possible. Moreover, the initial preparation and foundation work that was necessary before forming such a high level Council was lacking.
Under this Council is the , which is responsible for overseeing the operationalization and implementation of national policy and strategy, attending to the technical aspects of implementation and donor collaboration. This multi-sectoral committee consists of representatives of government, donors, NGOs and the private sector and advises the Council on technical aspects of policy and its implementation and supports district level implementation. Although this committee is represented by Joint Secretary (Class I level government officer) level officials from different line ministries, their presence in the meeting is either minimal or represented by a junior officers. This committee is also not as functional as anticipated, but has been able to translate a number of policies and strategies into practical action plans.
These national level experiences have been largely repeated at the district level where have been formed under the chairmanship of the District Development Committee. These mechanisms have also tended to be non-functional. There is continuing effort to make these a viable coordination mechanism to oversee the implementation of the Action Plan.
Despite these governance-related challenges, the National HIV/AIDS Strategy (2002- 2006) has been able to guide Nepal’s response to its HIV epidemic. The vision of the National Strategy is to . It has done this by focusing on activities within its 5 priority areas thereby optimizing prevention and reducing the social impact of HIV/AIDS in the most cost-effective manner. It aimed to operationalize the 1. Prevention of STIs and HIV infection among national policy and to vulnerable groups. define key activities for 2. Prevention of new infections among young people. each policy objective. 3. Ensuring care and support services are available Although the Strategic and accessible for all people infected and affected Plan (1997-2001) by HIV/AIDS contained a number of 4. Expansion of a monitoring and evaluation frame activities aimed at the through evidence based effective surveillance and prevention of a rapid research. spread of the epidemic, 5. Establishment of an effective and efficient only a limited number management system for an expanded response of prevention activities
12 were actually implemented. The current Strategic Plan sought to broaden the response to other sectors beyond health and integrate HIV/AIDS concerns within them. Factors relating to mobility of populations, urbanization, heavy labour migration are being addressed. The open border between Nepal and India and widespread poverty are now being recognized as an opportunity for the spread of the infection in the country, for example.
The National Strategy also emphasizes . The focus of the response is in as well as selected hill districts with high levels of out migration. The need for for people infected and affected by HIV/AIDS is also emphasised. This is not only important in its own right, but it is also contributes to effective prevention. Considering the dynamic nature of the HIV/AIDS epidemic, the National Strategy acknowledges the importance of accurately .
The Ministry of Health and Population has also promoted a as a principle in the National Strategic Plan. Awareness of greater HIV vulnerability of affected populations is being raised within the uniformed services to reduce incidence of harassment and violence. These are expected to mitigate against the impact of the current civil conflict on Nepal’s HIV/AIDS situation.
The government’s National HIV/AIDS Strategy was launched in January 2003, forming the A costing exercise was completed to estimate the resource requirements of the national HIV/AIDS strategy. It was estimated that for the period 2003-2007 US$95.9 million is required, naturally depending on how the strategy is operationalized. Based on the National Strategic Plan and the costed five-year plan, an annual operational plan is to be developed every year.
The Plan will also aim to . Improved facilities and equipment and better trained staff in HIV and AIDS at the district level will be an important aspect in the implementation of the Plan, in order to ensure that communities receive needed quality health care. Civil society organizations are key stakeholders in the implementation. Institutional development activities that will build on their existing technical experience and will improve resource mobilization and management will be a major focus in the annual plan.
During the first three years of implementation, it must be noted that the , for reasons that include political uncertainty, leadership changes and resource constraints. . In 2005, increased resource flows from the Global Fund to fight AIDS, TB, and Malaria and DFID were catalysts for increased multi-sectoral collaboration and harmonization of activities, resulting in the achievement of the first One, an agreed on 2005-2006 National Action Plan.
One of the greatest results of in Nepal’s HIV response was the that reflects shared priorities, harmonized resource allocations, and coordinated implementation mechanisms, including for monitoring and evaluation. The continually evolving partnerships increase coverage of prevention and treatment services, sustain
13 advocacy for an enabling environment, and ensure the active involvement of people with HIV and AIDS and other vulnerable groups. It has also paved the way for dialogues towards the achievement of the second mechanism – an overall institutional authority. Through increased dialogues and participation of all stakeholders, discussions to develop an effective institutional to oversee the national response are underway among the stakeholders and high-level leadership in the Ministry of Health and Population.
The National Action Plan is , especially affected communities. Approximately 65% of the needed resources for the Action Plan have already been pledged by external development partners, such as DFID, the Global Fund to fight AIDS, TB and Malaria, USAID, and the UN System. This support will make possible the scale-up of targeted prevention interventions, which will pursue a comprehensive package of services that include peer education, STI Nepal has been able to achieve the first of the three management, voluntary Ones which are: counselling and testing, • ONE agreed AIDS action framework condom distribution, and • ONE national AIDS coordinating authority community sensitization, • ONE agreed monitoring and evaluation among the priority framework communities. In addition, The National HIV/ AIDS Action Plan and Budget for increased resources for 2005-2006 was a key milestone in the country’s HIV treatment, care and response and was the result of an extensive support will expand the consultation process, with broad participation from numbers of people with civil society organizations and affected groups. HIV receiving antiretroviral treatment to 30%.
A recent study calculated Nepal’s composite policy index as shown in the figure indicates the in 2003 and 2005 (Figure 2). While improvements are seen in certain policy areas, there are clear areas where more intensive policy actions are required.
10 9 8 7 7 6 6 5 5 5 5 5 4 4 4 3 3 3 33 3 3 2003 3 2 2005 2 1 0 0 0 Source: USAID /Futures Group, Policy Project, AIDS Programme Effort Index in Nepal, 2005
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Recently, a was collaboratively conducted in June 2004 by NCASC, USAID, POLICY Project and Forum for Women, Law and Development (FWLD) towards developing an improved legal framework that best contributes to control further spread of HIV and to protect the rights of people infected and affected with HIV and AIDS. Mapping was done of the Constitution of the Kingdom of Nepal, 1990. In total of 280 Acts, 210 Regulations, 3 Executive Orders, 7 Policies, 3 Guidelines and 2 Draft laws to compare its consistency with standards contained in International Guidelines. , . Based on the study, Nepal has drafted an HIV and AIDS (Treatment, Prevention and Control) Bill and also Amendment Proposals on Existing Laws, which is now pending with high-level government bodies.
The dynamics of Nepal’s epidemic seem to be following a predictable course – a rapid increase in the most vulnerable groups and then spread via bridge populations into the general population. The top priority of the national response has been to prevent a generalisation of the epidemic in Nepal and has targeted intervention to the most vulnerable group (most – at – risk groups). Targeted prevention occupies . These prevention activities are . The national plan has classified 5 populations as most at risk and together with a sixth group, young people, they are the priority populations within the plan. The size estimates of the 5 most-at-risk populations are as follows in Table 4.
IDUs 16,500 23,200 MSMs 64,000 193,000 FSWs 25,400 34,100 Male clients of FSWs 564,000 754,000 Seasonal Labour Migrants 967,000 1,511,000 Source: NCASC/FHI 2005
The Policy Project’s 2005 Services Coverage study found a total of are reported in some 30 districts where during August 2004 – July 2005. These sites are largely operated by NGOs. NCASC has prepared VCT protocol 2004 which is being used by the VCT centres (Coverage survey 2005). The quality and types of services of those sites is not known and whether or not these sites offer comprehensive VCT services is not reported. Some VCT centres may be providing pre-test counselling and basic information only.
(a) Sex workers and their clients Female Sex Workers (FSWs) who are traditionally highly marginalised and often criminalised have little access to information and services. Cultural, economic and social constraints further limit their access to legal protection and to medical services.
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The emphasis of the national programme has continued for FSWs and their clients during 2003 to this reporting period with more than (2005/06) allocated for comprehensive package to FSWs. The Policy Project Services Coverage Study in 2005 indicated 60 – 77% coverage by outreach programmes in 22 major high-way districts, Kathmandu and Pokhara, largely undertaken by NGOs supported by FHI. Behaviour change information has been a key approach in these programmes, which includes local advocacy, behavioural change communications, community mobilisations and link to accessible, appropriate health services and commodities.
The total size of the FSW population varies enormously by location – a challenge for programme interventions attempting to reach the majority of FSWs. Nonetheless, the National Operational Plan (2005/06) aims to cover 70% of the total, including male sex workers.
The prevention programmes for sex workers have shown progressive results in terms of use of condoms which is reported to be 74% among the FSWs in Kathmandu and 53% in the Terai highway areas. This is further mirrored in the HIV prevalence among the FSW in Kathmandu where only 2% were found to be HIV positive. A study in 1993 had shown up to 17% prevalence among sex workers in Kathmandu. An emerging concern is that many young girls and women who engage in sexual activity in exchange for money or goods do not identify themselves as sex workers, and may not, therefore, be among the clearly identifiable sex workers who are reached by HIV services. The composite data of prevention programmes (including mass media, peer education, VCT and STI treatment) shows that only 35% of sex workers are reached by prevention programme. (see annex 3, indicators 4 and 6)
(b) Injecting Drug Users (IDUs) IDUs in Nepal are at risk not only by their injecting practices but also by a societal response, which ostracizes drug use and uses a predominantly punitive model coupled with limited drug treatment facilities (National HIV/AIDS Strategy 2002-6). The national efforts therefore remain focused on establishing a while at the same time continued building capacities of national NGOs for (including needle syringe exchange) with expanded coverage outside Kathmandu, made possible through Global Fund and DFID-supported activities.
has remained mainstay of the national programme for IDUs. However, the coverage and continuity of intervention followed by access to rehabilitation has remained a challenge. The composite programme reach index for IDUs is only about 8.6% - which clearly indicate that programmes are not reaching the larger population of IDUs scattered through the country (annex 3, indicator 4). Although a qualitative study reported to have reached 48% of IDUs, a thorough examination is required to ascertain the actual coverage. Nevertheless, those IDUs who are reached by the programme do have comprehensive knowledge on prevention of HIV. For example in Kathmandu 53% identified correct ways of prevention of HIV and also rejected major misconceptions about HIV transmission. Overall safe injecting practices were reported only from 34.5% of IDUs (IBSS, 2005).
16
,
According to LALS, an organisation working on Harm Reduction in Kathmandu valley, there are over 2,000 IDUs who utilized their needle syringe exchange programme (estimate of IDUs in Kathmandu 5-6,500) and a total of 14,491 times in 11 districts, including Kathmandu, IDUs were part of needle syringe programme during September 2004-September 2005 implemented by some nine NGOs (POLICY Coverage Survey, 2005). In addition, risk reduction information was also provided. Rehabilitation services are also being offered by 26 organizations with government or donor support. The total coverage for these services is on average 50 people per centre per year. Similarly, the size of the IDU population also varied by location and they are found to be highly mobile.
A challenge emerging from the National Action Plan’s implementation strategy for IDUs is oral substitution therapy. (Mental Hospital). Due to lack of financial and policy support, it has been discontinued for some time. In 2005/06 such facilities are expected to be available for 1000 IDUs from Teaching Hospital and BPK Memorial Hospital in Dharan and from some other major cities.
Despite the efforts to establish supportive HIV/AIDS policy, there is a further need to set in place a policy related to oral substitution, an effort now underway with the Ministry of Home Affairs. Furthermore, the comprehensive approach to deal with the needs of IDUs for HIV prevention and AIDS services – from demand to harm reduction to reintegration -- will require a collaborative strategy among the key Ministries of Health and Population, Home Affairs, and Labour and Development.
(c) Men having sex with Men Currently, Blue Diamond Society is the only organisation representing this most-at- risk population group. MSM are and therefore their access to prevention services is believed to be low. are reported to have reached by outreached programme within Kathmandu valley (POLICY Coverage Survey, 2005).
Most MSM are married due to social obligations, therefore they are exposed to sex with the spouse and multiple partners. A focused group discussion (FGD) conducted among the MSMs indicated that wives of MSM do not know the sexual orientation of their husbands, therefore they have in this way. The same FGD reported that MSM face harassment from police and security personnel for carrying condoms.
Programme reach for MSMs is only 5.4% (see Annex 3 indicator 7). Although size of MSM in the country is being estimated more vigorously to obtain actual information, the current estimation is somewhere between 64,000 – 193,000, which certainly indicates the need for careful programme intervention. A study reported 63% condom use among the MSM, whereas the Focus Group Discussion reported that condom use among TAs (more masculine MSMs) is very low they consisted of armed forces, security guards, rickshaw pullers and night taxi drivers despite the fact that they are reported to be aware about the risk of HIV/AIDS.
17
There are number of challenges facing the MSM component. , Secondly, ascertaining the actual size of the MSM population is difficult, especially as it is a hidden group and is forbidden by law. The outreach strategy to reach the community levels with information and services is promising but will require an extensive network and intensive inputs. Thirdly, other organisations committed to HIV prevention should find a role to play and support in MSM programme. This multi-pronged approach, while increasing coverage of services, will also help in creating a favourable social environment.
(d) Mobile populations Due to and lately labour migration to India and other countries have increased many folds over the period. It is estimated that to India, Gulf countries and East Asian countries like Malaysia, South Korea and other location. The pre departure and post arrival services including counselling are lacking. Studies conducted in the far west indicate high vulnerability of migrants and their spouse to HIV/AIDS and other infections coupled with low access to health and preventative services.
In a UN/New Era study conducted in 6 districts outside Kathmandu among migrant labourers in 2005 under the support of GFATM, a high level of knowledge (mid to high 90s) on HIV, STIs, and AIDS was reported, especially among the 20-29 age group. However, less than half of the respondents would use condoms whether with their wives or sex workers. Only 6% of the respondents reported sexual intercourse with sex workers, and 8% reported having sex partners other than their wives and sex workers. A more revealing dimension is the perception among the respondents of HIV and AIDS are consequences of immoral sexual behaviour, indicating the need for the integration of stigma and discrimination messages in HIV prevention efforts.
The programme for mobile population varied with some focused interventions, such as VCT set up at Doti Hospital (CARE Nepal) to youth mobilisation programme (SoVAA programme Save the Children (SC) Norway) and safe migration programme (FHI/SC-US). Although a number of organisations have initiated training and supportive activities in care and support programmes in high migration districts, a concrete model and programme is lacking for care and support. The programme reach for migrants have been very low with only 0.04% covered.
There is general consensus the efforts addressing mobile populations need to be intensified. The GFATM-supported programme highlights this sector as a priority. As initiatives were only started in mid-2005, prevention education and HIV counselling and testing services are reaching only a fraction of this group (annex 3, indicator 4). In six districts, some 20,000 migrant labours have received HIV information and counselling through district-based centres. Scale-up of these programmes are being planned. , ,
(e) Uniformed services Royal Nepal Army, Nepal Police and Armed Police constitute some , with varying levels of health and preventative services. STI treatment, VCT and supportive service are reported to be available within the system (Army Hospital and Police Hospital) the information and
18 awareness message is believed to be inadequate. In addition, the sexual behaviour of these groups is not known. A systematically implemented peer-based HIV prevention programme by the Royal Nepal Army and the Nepal Police has been initiated under the GFATM-supported programme. At the end of 2005, 5000 members of these two arms of the uniformed services have received HIV prevention education. Recently, PSI has conducted a behavioural study with technical input from FHI, results of which are due in 2006.
(f) Young people Young people constitute who are regularly exposed to vagaries of conflict, socio economic deprivations whose vulnerability is further compounded by peer pressure, ambitions and poor access to information and services related to health and reproductive information.
In the 2005 UNAIDS/New Era Behaviour, Information, and Services (BIS) Survey, broadcast media (TV and radio) was recorded as the primary source of information on HIV/AIDS. A surprising but positive finding was that, among young people who would have sexual intercourse with sex workers, . It closely correlates with consistent condom use of those who had sexual intercourse with sex workers in the last 12 months (71%).
A study conducted among 2748 youths has indicated that only 57% of youth said that it is easy for them to obtain information about HIV/AIDS (RHIYA/UNFPA 2005). Nonetheless, 91 % of respondent in the same study reported being aware of the ways of avoiding HIV/AIDS. Premarital sex among the boys (13%) was quite high compared to girls (2%) and condom use in their first sexual contact was found to be only 14%.
The about HIV/AIDS and reproductive health but the adequacy of the information and delivery of it has often been concern. There are major intervention targeted to youth, which is expected to provide access to information and services. Some of the notable activities are youth friendly services centres, life skills based media programme, life skills based education, sexual and reproductive health activities. Some 30 districts (including GFATM supported 6 districts) are covered by focused programme where as edutainment media is expected to reach though out the country. UNFPA and UNICEF are among the major supporters of the programme as a multilateral, whereas Nepal Red Cross and International Planned Parenthood Federation (IPPF) through Family Planning Association of Nepal are the non-governmental sector working with Youth. FPAN covers some 30 districts and Red Cross covers 32 district with youth focused programme within the school and outside.
Extensive peer education programmes have been launched in 2005 under the GFATM programme. At the end of 2005, the programme has reported reaching close to 50,500 in and out-of-school young people. With injecting drug use as the primary mode of transmission, the young population will continue to be a priority.
The figure below shows a comparison of the coverage of selected services in 2003- 2005.
19
50000 40000 30000 20000 10000 0 2003 2005
Source; USAID/Policy Project, Coverage of Essential HIV/AIDS Services in Nepal, 2005
(g) Emerging priority groups Workplaces There is strong evidence that private sector is attracting a larger workforce then ever before, clearly indicating clear shift from agriculture to production sector where 44% increase in labour force recorded in 2001 compared to 1991 (private sector 47,100; Public sector 376,000) 14 . Following a partnership programme of FNCCI with UNAIDS and the ILO, on education and awareness programmes for employers and workers in the Nepalese formal private sector initiated in 2002. A more comprehensive pilot programme has been initiated in 10 major private enterprises with assistance from ILO. Out of ten enterprises, seven have already developed their own internal workplace policy based on ILO code of practice.
In 2003 a 13 - member National Steering Committee for Workplace was constituted with representatives drawn from government (chair), NGOs, PLWHAs, Private sectors and UNAIDS and ILO.
A workplace policy has been developed by jointly FNCCI, Trade Unions and Government with support from ILO and UNAIDS which is awaiting government endorsement. National Steering Committee has already endorsed it and has forwarded to government for final endorsement. The policy is expected to guide the private enterprises to develop workplace programme for the employees and workers. Operation Plan 2005/06 envisage further support in terms of expanding services like awareness raising, peer education and VCT referral in the private sectors.
Marginalized groups Experiences of NGOs and UNESCO with trafficked girls & women and street children, respectively, have indicated the need to address the HIV prevention and care needs of these two groups. Maiti Nepal, the leading NGO in the trafficking area, has reported growing levels of HIV infection among young girls it has rescued.
14 HIV/AIDS vulnerability assessment among Trade Unions, GEFONT/SARDI (2005) Kathmandu (Unpublished)
20
UNESCO completed a study in November 2005 that reported that only 20% of street children in Kathmandu had been exposed to an HIV prevention activity.
,
(a) Antiretroviral therapy There are in Nepal. PLWHAs who have some resources often run community care centres. Service offered at these centres are nutrition, referral to district hospitals or private facilities for medical care, HIV testing, counselling and psychosocial support for PLWHAs and their families. According to one study, HIV positive injecting drug users receive more support than any other group affected/infected by HIV/AIDS.
Initiation of care and support programme for infected and affected groups has been rather late, having only started in a systematic manner in 2003. Although national guideline for ARV treatment was developed and finalised in 2004, ARV treatment was started in 2003 (for 77 PLWHAs). Currently there are about 160 (30% women) people receiving ARV treatment from seven locations in which two sites being outside the Kathmandu (Dharan and Nepalgunj). About 450 patients will be provided with ART through currently available funding from the government. With the Global Fund and other sources, a total target of 1,000 patients to be provided with ART has been set under the National Operational Plan for 2005/2006.
(b) PMTCT, paediatric AIDS and orphans & vulnerable children (OVC) The NCASC conducted a situation assessment in July 2004 in order to initiate the in Nepal 15 . A PMTCT Working Group was established and the government introduced National Guidelines for the PMTCT 2004 and is in the process of updating. Currently there are three pilot sites and expected to . It was reported that some 2306 women received PMTCT services during July 2005 – November 2005. This service could be just counselling only and not comprehensive (Coverage survey 2005)
According to estimates used in the National Action Plan 2005-6, there are just over 900 children (under 15 years) with HIV and 10% of these are in need of ARVs. A paediatric AIDS diagnosis and treatment guidelines draft was developed in September 2005 and in the process of being finalized. A plan of action to initiate paediatric AIDS programme from 2006 is in place.
Through an initiative in Accham district, an INGO with local partners have started to provide psychosocial support including play-skill tools to all children orphaned by HIV (now over 50) and educational support including books, stationery, etc. to all orphans. Another INGO in Rupandehi district is supporting 50 children of sex workers.
15 PMTCT in Nepal, Situation Assessment and Recommendations, 2004 July, Elisabeth A. Preble, MPH, Consultant, UNICEF/Nepal
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Government (Ministry of Health) funding for HIV/AIDS has been rather meagre despite that fact the allocation has increased every year. The direct spending on HIV/AIDS is less than one percent of overall HIV/AIDS Programme budget for 2005. The non-direct spending e.g. expenses for treatment of STI and other opportunistic infections through regular health delivery system, spending of ministry education in preparing curriculum and delivering the lessons at the secondary school through out the country and similar costs have never been calculated.
Programme Cost 65,629 68,057 105,071 Management Cost 26,343 27,743 41,586 Total (HMG) , , , Utilized/Spent 80,293 82,000 %
Total budget (planned) 7,166,740 8,927,850 23,621,814 Pledged by EDPs 2,550,864 5,468,601 14,506,383
The overall health budget is US$ 93.6 million which is over 5% of national budget for fiscal year 2004/2005. The current health budget is certainly an increase compared to the previous year. However relative to spending in other sectors health spending is low (Figure 4) and further increases in government health spending seem unlikely, if not impossible.
,
The World Bank/Nepal (January 2004) initiated a study on the relative cost- effectiveness of the individual programmes that are classified as Essential Health Care Services (EHCS) (Table 6) to help country in prioritising resource mobilisation. Although some of the costs are now outdated, the cost effectiveness analysis is
22 expected to be important for priority setting if not all resources needed for up-scaling the EHCS can be mobilized over the coming years 16 .
1,405 Vitamin A 1.0 972 TB 6.5 NA Iodine 8.1 1,115 EPI 14.2 927 FP 17.7 3,984 IMCI 24.8 2,320 S. Motherhood 28.7 126,393 Leprosy 32.1 NA Outpatient 34.1 , 5,872 Vector Borne 70.2
Although cost per DALY for HIV/AIDS appeared high, the cost per death averted compares well with other EHCS packages like Vitamin A, EPI and Family Planning (FP) among others.
There is general perception among the policy makers within Ministry of Health and outside that HIV/AIDS programme components are adequately funded by donors, therefore scarce national resources should be allocated to other priority areas. Moreover, in the context where overall health spending in the country heavily depends on private spending and EDPs assistance (Table 7), coupled with conflicting priority as set in cost effective analysis substantial increase in HIV/AIDS spending require considerable efforts and adjustment in government funding priorities.
Private 70% EDPs 13% MOH 14% Other Public 3%
16 The World Bank Nepal, Costing of the Nepal Health Sector Program-Implementation Plan with Unit Cost of Essential Health Care Services (EHCS) as cited in NHSP-IP
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Over the last two years, the momentum regarding HIV/AIDS has increased. The number of partners involved in the response to HIV/AIDS in Nepal has increased and in general, more focus is being put on this issue. This is partly evident due the increased funding from various international donors present in Nepal as well as driven by need in the country.
National organisations both NGOs and private organisations have been increasing their involvement in HIV/AIDS activities. FHI reported having more than 53 partners implementing various programmes. Similarly, an inventory prepared by NCASC showed more than 120 organisations working in various aspects of HIV/AIDS (e.g. awareness, BCC, research, service delivery, VCT, ARV support and so on). The GFATM and DFID programmes have a partner network of some nineteen organisations. In addition, NAP+N, a network organisation of positive groups is coordinating implementation of special programme for 18 PLHWAs organisations through out the country for capacity development as part of DFID assistance called the Challenge Fund. There are ongoing efforts to minimize logistic, financial and operational difficulties in the planning and implementation of activities.
Another example of a prominent organization’s involvement in HIV/AIDS efforts, the Nepal Administrative Staff College has continued to integrate HIV/AIDS issues into its regular curriculum in the training of government officers and general staff. Other stakeholders have also become increasingly involved in the response to HIV/AIDS in Nepal. As described in a previous section, the FNCCI has made great progress in some partnerships, but one that needs revitalization is with the Asian Business Coalition on AIDS with whom an MOU was signed in December 2002.
More importantly, this reporting period saw an impressive development of organisation and networks of vulnerable groups like MSM, PLWHAs, IDUs, sex workers, returned migrants women. These groups are now increasingly involved in national forums, in development of annual programmes, and in other consultation process. With the involvement of these groups, it is expected that policy and programme would be specific to their needs while at the same time help government and other stakeholder to realise the principle of greater involvement of people living with AIDS.
The media sector has made it contribution to the response to the epidemic. Policy Project/USAID has sensitized and developed a media reporting guideline based on a media review conducted in 2004 to analyze the reporting of HIV/AIDS in Nepal (POLICY, 2004).
As part of the National Action Plan (2005-6), an orientation for religious leaders has been conducted after a regional consultation in Kathmandu at the end of 2003. This is a component for advocacy and awareness-raising among young people and the general population.
Many external development partners have joined forces to collaborate with the government of Nepal to address the epidemics. The emphasis of the programme is on prevention particularly among the high risk behaviour groups while at the same time adequate attention has been given to vulnerable population as well as care and support to PLWHAs. Following the emergence of many self-help groups of PLWHAs, MSMs, returned migrants and IDUs, the HIV/AIDS programme is being implemented
24 in collaboration of these groups. In 2005 major partners allocating resources for HIV/AIDS preventions is as follows in Table 8.
DFID 4,797,456 33.07 USAID 4,739,924 32.67 GFATM 2,621,315 18.07 Nepal Red Cross 585,070 4.03 CrossCrossAusAid 406,238 2.80 FPAN 305,274 2.10 UNDP 186,000 1.28 UNICEF 182,500 1.26 UNAIDS 172,000 1.19 HMG 144,606* 1.00 UNFPA 120,000 0.83 WHO 100,000 0.69 ILO 85,000 0.59 World Bank 50,000 0.34 UNESCO 11,000 0.08 , , , ,
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There are a number of challenges to the implementation of Nepal’s National HIV/AIDS Strategy, the delivery of its UNGASS priority commitments. The priority challenge is to build the institutional capacity for effective HIV/AIDS responses among key actors. For example, the roles and capacities of NGOs’ have developed during the reporting period and these organisations are now providing a range of services to vulnerable groups. Broadly speaking, however, capacity for monitoring and evaluation, surveillance, care and support interventions are among the areas that require attention.
Currently NCASC, a nodal agency for HIV/AIDS programming and policy development in Nepal is facing a number of challenges. Firstly, , , unravelling realities of HIV/AIDS, increasing commitment and capacity of NGOs and EDPs and the need for additional resources. The requirement for capacity building within the NCASC will entail the engagement of professional and administrative staff with appropriate competencies and a professional development plan.
The second major challenge is the . The location and mandate for this national structure is very crucial as it should be able to overcome the current anomalies and promote multi-sectoral response to the epidemic. This includes the development and confirmation of the accountabilities, roles and responsibilities of the NAC, NACC, and NCASC, including a mechanism for execution. The resolution of these issues will allow HMG/Nepal to apart from rapid scaling up the efforts, lead and 1. A robust, responsive NCASC manage the response to 2. An effective national coordinating structure HIV/AIDS, create effective 3. Systematic research on the HIV/AIDS policies and legislation, build context and influences behind the spread capacity and partnerships for 4. HIV prevention, treatment, care and implementation, and advocate support training at decentralized levels for social mobilization.
Based on the national HIV/AIDS Strategy, a fully-costed National Operational Plan for HIV/AIDS Control is in place, which provides a framework for developing Annual Operation Plan. The current proposed implementation modality in the strategy is for an external executing agency, reporting to the National AIDS Coordination Committee to develop an implementation plan(s) and to provide program management services. This external executing agency would receive technical direction and oversight from the NCASC. This modality has not yet been confirmed.
The third major challenge is the , of HIV/AIDS in Nepal. The resolution of this challenge lies in the development of the NCASC’s surveillance and research, and monitoring and evaluation capacities.
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The greatest obstacles to effective prevention often relate to stigma, disregard for human rights, and counterproductive policies. There are , . Scaling up the effort is crucial to combat the epidemic as evidenced by the current coverage data available. For this, a collective effort is essential where EDPs also extend hand along with national and international non governmental organisations. Expanding the reach of programmes for marginalized groups will require complementary programmes and policies aimed at creating favourable conditions for the provision of HIV and AIDS services. These include legal and policy changes to fight discrimination against people with HIV and AIDS, removal of practical barriers to access to services, and campaigns to reduce vulnerability of girls and women.
Furthermore, UNGASS commitment invariably calls for concerted and expanded response from member countries. Business as usual is not adequate. Following matrix highlights the key actions required to achieve UNGASS goals and over come challenges.
1. Strong • Poor functioning of national • Advocacy for appropriate at coordination mechanisms, institutional arrangements for all levels resulting in poor policy support HIV/AIDS response
• Emerging district leadership, • Leadership development but too decentralised without programme central-level support • Technical and policy support • Weak response to multi- including resource allocation sectoral collaboration from other ministries
2. • Limited coverage and quality • Technical capacity building and the mainstay of information and services resource mobilisation for of the improvement response • Difficulty setting time-bound indicators for measuring • Enhanced capacity and results commitment from government, NGOs and external • Establishing workplace development partners for policies and interventions scaling up
• PMTCT services inadequate • Implementation of recently developed workplace policy
• Expansion of PMTCT to priority rural areas (almost 80% home deliveries)
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3. • Current policies, strategies • Develop policy and strategy for , and programme inadequate care, support and treatment. • Poor ARV coverage (160 • Increase ARV access through are patients in 2005) and resource mobilisation fundamental continuity of services
4. Realizing • Some discriminatory laws and • New HIV/AIDS bill has been regulations drafted for government are approval. Lobby groups to essential to • Gender and women’s create pressure. reduced empowerment inadequately vulnerability addressed by strategy • Advocacy and capacity building of government and civil society • Discriminatory behaviours on gender sensitive planning persist at service provision outlets including health care • Technical and other support to settings reduce discriminatory behaviour in services
5. • Programme coverage focused • Expansion of successful on youth and mobile models (e.g. youth radio especially of populations, but wider access programme; youth friendly women needed information and service centres) 6. Assistance to • No special programme in • Incorporate into policy, strategy HIV/AIDS place and programme with provision orphans and of adequate resources vulnerable
7. Alleviating • HIV impact recognised in • Conduct socio-economic the multi-sectoral national policy, impact study to promote and but not supported by ministries guide strategy development of all sectors and without strategies, resources and • Technical and policy support to through action government to develop multi- sustainable sectoral strategy development
8. • No national capacity for • Continue with current research biomedical research activities with expansion in other critical areas identified • National institutions are undertaking social and behavioural research
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9. • Limited knowledge of the • Deeper understanding of the - impact of current conflict on impact of the conflict through affected the spread of HIV/AIDS, other field research regions HIV-related risk factors and service delivery
10. New, • Budget shortfall for planned • Advocacy for appropriate additional activities government planning and and resource allocation for sustained • Low government’s contribution HIV/AIDS mainstreaming in all to programme budget (only ministries are required 1%, although indirect contributions not calculated) • Increase EDPs commitment for financial and technical support • Pledges of EDPs insufficient
• Weak absorptive capacity (particularly in government)
11. • No standardised or routine • National capacity building and and HIV/AIDS M&E system; ad- establishment of appropriate monitoring for hoc project and programme M&E system for HIV momentum monitoring by implementing agencies
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External Development Partners (EDPs) have played a vital role in country’s development initiatives including in the area of HIV/AIDS. Some of the critical areas where EDPs support required are as follows.
In order to have an effective expanded, multisectoral and coordinated response to the epidemics, the needs to be seriously considered. The scope and capacity of current institutional set up within the purview of Ministry of Health is structurally limited to move beyond the health sector. Therefore an appropriate institutional mechanism needs to be developed where sectors outside the health would have a role to play. The EDPs can assist government of Nepal, both technically and financially in developing an appropriate institutional mechanism.
Similarly, NCASC being a nodal agency for HIV/AIDS programme and policy development should focus on for which EDPs needs to join hand in building the capacity of NCASC with proper system, facility and staffing.
Donor coordination and harmonisation is important aspect not only to build national system but also for coordinated response for HIV/AIDS. While current coordinating mechanisms such as UN Theme Group; Association of International NGOs; regular Donors Meetings (MOH) have been useful, but due to lack of and resource harmonisation, multisectoral response has not been fully achieved. EDPs therefore should explore the possibility of mechanism for coordination and harmonisation.
A national monitoring framework and mechanism is long overdue. In absence of an , tracking the achievements, resource flow and input to policy development has often been rather ad hoc scattered. EDPs should assist the government to set up a national HIV/AIDS monitoring and evaluation mechanism urgently.
The commitment to scale up has several important implications: i) the health care system, in terms of personnel at national and district levels, must receive intensive and up-do-date ART training, especially for monitoring compliance and detecting drug resistance; ii) the current system for logistics and supply management needs technology and infrastructure augmentation; iii) laboratory facilities must be likewise upgraded. These extensive needs are areas where external technical and financial support is clearly needed.
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Current monitoring environment is only where each of implementing organisations monitor their results and often shared with stakeholders. The Ministry of Health monitors its national health programme on quarterly basis. HIV/AIDS related activities conducted by MOH are also shared in the form of activities, outputs and some epidemiological data reported by District Health Offices (e.g. number of STI cases in the district, and number of HIV cases detected). NCASC with support mainly from FHI conducts surveillance every alternate year. The BSS and IBBS have been major sources of behavioural and sero data for policy development, programme management and enhancing the deeper understanding on dynamics of HIV/AIDS. The latest BSS covered some 22 districts along the major highways
There is that captures epidemiological and behavioural data does not exist. The IBBSS and BSS conducted periodically with technical and financial assistance of FHI/USAD is monitoring the changes and results both on behaviour and sero prevalence of most at risk population at major areas of 22 districts.
While the National Strategy has envisaged a functional monitoring and evaluation within the NCASC, it had not materialised at the time of this report. National Operation Plan (2005/06) has envisioned to initiate the process and the Global Fund also had planned to support toward setting up a national monitoring mechanism. As indicated by this report, information on the status of the national response is limited to several key partners. However, there are other .
As reported in the Millennium Development Goals: 2005 Progress Report , HMG/Nepal’s current HIV/AIDS M&E capacity will require considerable development. According to this report, in the following areas:
Data-gathering capacities - weak Quality of recent survey information - fair Statistical tracking capacities - weak Statistical analysis capacities - weak Capacity to incorporate statistical analysis into policy -fair Monitoring & evaluation mechanisms - weak
The report indicated that without intensified and accelerated HIV prevention efforts, Nepal will not achieve its Millenium Development Goal of halting and reversing the spread of HIV by 2015. An improved monitoring and evaluation environment will be crucial to achieving any such goal in the future. .
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Annex 1: Consultation/preparation process for the national report
Consultation/Preparation Process for the National Report on monitoring the follow-up to the Declaration of Commitment on HIV/AIDS The National Centre for AIDS and STD Control (NCASC), Dr. S.S. Mishra, the Director, coordinated the Report writing process. A National Task Force was formed by the Ministry of Health and Population to oversee, support and assume active role in report preparation process. The Task Force approved the active participation of all the sectors within the task force during the data generation and consensus building process. The final report was also endorsed by the task force before submission to UNAIDS Geneva. Overall the task force met three times to deliberate on and finalise the report. The National Centre for AIDS and STD Control through its senior management staff coordinated the process of data collection, consultations and consensus building. The National Centre for AIDS and STD Control through the financial assistance from UNAIDS recruited a consultant (UNGASS Technical Coordinator) to facilitate the process of data collection, collation and reporting writing. Technical representatives from NCASC, UNAIDS, USAID, UNFPA, MOHA, MOF, NPC who are also member of the task force were assigned to guide the consultant and the indicator group to act as reference group during the process. The Reference Group met about three times during the period. The Indicators Working Group, which is made up of primarily from NGO partners, met twice to validate the report. Earlier in May 2005 NGOs had organized a workshop on UNGASS where NGOs had formed thematic group representing themes like, migration, youth, gender and so on. While constituting the indicator group, previous grouping were also taken into consideration. Prior to beginning the data collection, the NGO partners were oriented on UNGASS reporting process and data collection procedures. The NGOs were voluntarily asked to take a lead on one specific indicator for data collection and conducting consultation and Focus Group Discussions with their own constituencies. The indicator groups (responsible organization in parenthesis) were as follows.
1. Government funding - HIV/AIDS (NCASC) 2. National Composite Policy Index: (NCASC, • Strategic plan (NCASC, MOH) • Political support (NANGAN) • Prevention (Red Cross, YPN) • Care and support (NAP+N, Recovering Nepal)
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• Human rights (FWLD) • Civil society involvement (NANGAN, FNCCI) • Monitoring and evaluation (FHI, UN)
3. Most-at-risk populations: HIV testing (Richmond Fellowship Nepal, NAP+N) 4. Most-at-risk populations: prevention programmes (Recovering Nepal, NAP+N, HSWO, SISo, BDS)
5. Most-at-risk populations: knowledge about HIV prevention (NANGAN, NRCS, SISo Nepal) 6. Sex workers: condom use (WATCH, WOREC, PSI, GWP) 7. Men who have sex with men: condom use (BDS) 8. Injecting drug users: safe injecting and sexual practices (NHRC, Richmond Fellowship, Recovering Nepal)
9. Most-at-risk populations: reduction in HIV prevalence (NCASC) A National Consultation Forum was organized in January 2006 to consult and build consensus on the analysed data and the report content prior to endorsement by the Ministry of Health and Population. The planning, data collection and analysis, consultation and consensus building was from late September 2005 to mid-January 2006. The data collection primarily consisted of collecting and reviewing secondary data available in each of the indicator. Besides, indicator group organized mini consultations with their own constituency and relevant partners to get qualitative information to complement the quantitative secondary data. During the process, UNAIDS and NCASC were available to support and guide the process.
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Dr. HN Acharya – Chair Dept of Health Services,Ministry of Health and Population
Dr. Shyam Sundar Mishra Acting Director, NCASC – Overall Coordination of the UNGASS process
Revati Raj Kafle National Planning Commission
Deepak Kharel Ministry of Finance
Aurorita Mendoza UNAIDS Country Coordinator
Sharon Ascot Mills USAID
Mahesh Sharma UNGASS Technical Coordinator
Rajiv Kafle PLWHAs (NAP+N)
Hari Awasti NANGAN
Bijaya Pandey Recovering Nepal
Narayan Kaji Shrestha WATCH
Sunil Babu Pant Blue Diamond Society
Rishi Ojha National Harm Reduction Council
Bishnu Sharma Richmond Fellowship Nepal
Sheldon Allen Report Editor
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Aurorita Mendoza Pulkit Chaudhary Country Coordinator Medical Officer UNAIDS NCASC
Bina Pokharel Rishi Ojha Technical Advisor President POLICY NHRC/YPN
Bipul Neupane Robert Thomas Programme Manager Strategic Information Advisor Nepal Red Cross Society UNAIDS
Deepak Kharel Rup Narayan Shrestha Under Secretary Programme Officer Ministry of Finance FWLD
Hari P. Awasthi Salina Tamang President Programme Officer NANGAN Blue Diamond Society
K.S. Karki Saraswati Sapkata Programme Officer Programme Officer Save the Children/Norway LALS
Laxmi Bilas Acharya Sharon Arscott-Mills Team Leader Sr Technical Advisor, HIV/AIDS FHI Nepal USAID
Lochana Shrestha Shyam Sundar Mishra Medical Officer Director NCASC NCASC
Mahesh Sharma Sunil B. Pant President UNGASS Technical Coordinator Blue Diamond Society UNAIDS Prasuna Sharma Manju Karki WOREC HIV/AIDS Officer UNFPA Bijaya Pandey Executive Director Prakash Chandra Ghimire Recovering Nepal Chief, Assoc. Coord. Section Isshwor Shrestha National Sports Council FNCCI
Bishnu Sharma Coordinator Richmond Fellowship Nepal
35
Khumanand Subedi Bipul Neupane Executive Director Nepal Red Cross Society SISo-Nepal New Baneshwor, Kathmandu Kathmandu Deepak D Bhatta Jagadish Chandra Bhatta PSI/Nepal Member Secretary Budhanilkantha NANGAN Bijuli Bazar, Kathmandu Bhanu P Dhakal NANGAN Women Acting Together for Change Kathmandu (WATCH) Battisputali, Kathmandu Elen Alen (VSO) NANGAN Bishnu Sharma Kathmandu Programme Coordinator Salina Tamang Richmond Fellowship Nepal BDS Kathmandu Kathmandu
Rup Narayan Shrestha Sudan Rai Advocate Blue Diamond Society FWLD Kathmandu Thapathali Puspa Lal Moktan Rishi Ojha PMU/MSA UNDP President (Facilitator) Nepal Harm Reduction Council Anamnagar Kathmandu Prasuna Sharma WOREC Bijaya Pandey Balkumari Recovering Nepal Lazimpat
36
Prasuna Sharma WOREC Rosie Khadgi Balkumari Sahara Plus Kathmandu Bijaya Pandey Recovering Nepal Jeevan Ghale Lazimpat Richmond Fellowship Nepal Lathmandu Khumanand Subedi Executive Director Ekata Mahat SISo-Nepal New Baneshwor, Recovering Nepal Kathmandu Lazimpat
Rup Narayan Shrestha Sheron Ascot Mills Advocate USAID FWLD Kathmandu Thapathali Madhav Raj Bista Salina Tamang NAFA BDS Kathmandu Kathmandu Tatwa Timsina Iswor Shrestha NANGAN FNCCI Kathmandu Kathmandu Ram Kumar Bidari Bina Pokhrel Nepal Red Cross Society Policy Project Kathmandu Kathmandu
37
Annex 2: National Composite Policy Index Questionnaire
(Multisectoral strategies should include, but not be limited to, those developed by Ministries such as the ones mentioned below.) √√√
1.1 IF YES, which sectors are included? Health √ √√√ Education √√√ √ Labour and Transportation √√√ √√√ Military √√√ √√√ Women √√√ √√√ Youth √√√ √√√ Others to specify:
Comments : *
1.2 IF YES , does the national strategy/action framework address the following me areas, target populations and cross-cutting issues? ( Yes/ No )
a Voluntary counselling and testing a Yes b Condom promotion and distribution b Yes c Sexually transmitted infection prevention and treatment c Yes d Blood safety d Yes e Prevention of mother-to-child transmission e No f Breastfeeding? f No g Care and treatment? g Yes h Migration h Yes i Women and girls? i Yes (limited) j Youth? j Yes k Most-at-risk population? k Yes l Orphans and other vulnerable children? l No m HIV/AIDS and poverty? m No n Human rights? n No o PLHA involvement? o Yes
1.3 If yes, does it include an operational plan? 1.4 If yes, does the strategy/operational plan include
38
a. Formal programme goal b. Detailed budget of costs? c. Indication of funding sources?
1.5 Has your country ensured “full involvement and participation “of civil society in the planning phase? 1.6 Has the national strategy/action framework been endorsed by key stakeholders?
Comments: National Operation Plan was development by a team consisting representatives of civil society organisations, government and EDPs. Larger civil society organisations were consulted many times during the course of planning
, ,
Yes √√√ No N/A
2.1 IF YES, in which development plan? (a) (b) (c) ……Other
Covering which of the following aspects/ (Yes/No)
a) b) c) HIV prevention Yes Yes Care and support Yes HIV/AIDS/AIDS impact alleviation Reduction of gender inequalities as relates to HIV/AIDS/AIDS prevention/care Reduction of income inequalities as relates to HIV/AIDS prevention/care Others
Yes No √√√ N/A
3.1 IF YES , how much has it informed resource allocation decisions? ( Low to High )
Comments:
, ,
39
√√√ No N/A
4.1 IF YES, which of the following have been implemented?
HIV Prevention Yes √ No Care and support Yes √ No Voluntary HIV testing and counselling Yes √ No Mandatory testing and counselling (compulsory) Yes √ No Others to specify Yes No
Comments :
, 2005 Poor Good 0 1 2 3 4 5 6 √√√ 8 9 10
2003 Poor Good 0 1 2 3 4 √√√ 6 7 8 9 10 In case of discrepancies between 2003 and 2005 rating, please provide main reasons supporting such differences.
40
Strong political support includes government and political leaders who speak out often about AIDS and regularly chair important meeting, allocation of national budgets to support the AIDS programmes and effective use of government and civil society organisations and processes to support effective AIDS programmes.
Head of government Yes √ No Other high officials Yes √ No
Yes √ No N/A 2.1 IF YES, when was it created? Year National AIDS Council was created in 2002 chaired by prime minister
2.2 Does it include? Terms of reference Yes √ No Defined membership Yes √ No Including civil society Yes √ No People living with HIV Yes √ No Private sector Yes √ No Action plan Yes No √ Functional Secretariat Yes No √ Date of last, meeting of the Secretariat (Council) Date: July 2005 Comments: National Centre for AIDS and STI Control (NCASC) acts as secretariat for the Council.
, ,
Yes √ No N/A
3.1 IF YES , does it include? Terms of reference √√√ Defined membership √√√ Action plan √√√ Functional Secretariat √√√ Date of last meeting
41
Comments: National AIDS Coordination Committee formed in 1997 with the aim of promoting interaction between government and other sector was to promote collaboration and multisectoral response to the epidemic.
Yes No √ N/A
4.1 IF YES , does it include?
Terms of reference Defined membership Action plan Functional Secretariat Date of last meeting
Comments:
, 2005 Poor Good 0 1 2 √√√ 4 5 6 7 8 9 10
2003 Poor Good 0 1 2 3 4 √√√ 6 7 8 9 10 In case of discrepancies between 2003 and 2005 rating, please provide main reasons supporting such differences.
Frequent political changes and changing political priority
42
,
Yes √ No N/A
1.1 In the last year, did you implement an active √√√ programme to promote accurate HIV and AIDS reporting by the media?
Comments :
Yes √ No N/A
2.1 Is HIV education part of the curriculum in:
Primary school? Secondary school? √√√
2.2 Does the strategy/curriculum provide the same √√√ reproductive and sexual health education for young men and yon women?
Comments:
,
Yes √ No N/A
3.1 Does your country have a policy or strategy for these most-at-risk population?
Injecting drug users, including: √√√ - Risk reduction information, education and counselling? √√√ - Needle and syringe programmes? √√√ - Treatment services √√√ - If yes, drug substitution treatment? √√√ Mean who have sex with men? √√√ Sex workers √√√ Prison inmates? √√√ Cross-border migrants, mobile populations √√√
43
Refugees and/or displace populations? √√√ Other most-at-risk population? Please specify √√√
Comments: There is programme for IDUs, MSMs, SWs and mobile population though there is no specific policy or strategy for those groups.
, , , , , ,
Yes √ No N/A 4.1 Do you have programmes in support of the policy or strategy?
A social – marketing programme for condoms? √√√ A blood –safety programme? √√√ A programme to ensure safe injections in health care settings? √√√ A programme on antenatal syphilis screening? √√√ Other programme? Please specify
Comments: , 2005 Poor Good 0 1 2 3 √√√ 5 6 7 8 9 10
2003 Poor Good 0 1 2 √√√ 4 5 6 7 8 9 10 In case of discrepancies between 2003 and 2005 rating, please provide main reasons supporting such differences.
Policy makers and senior bureaucrats are more aware about the HIV/AIDS issues. (Check all programmes that are implemented beyond the pilot stage to a significant portion in both the urban and rural populations)
a. A programme to promote accurate HIV and AIDS a. a. √ reporting by the media b. A social-marketing programme for condoms b. √ b. √ c. School based AIDS education for youth c. √ c. √ d. Behaviour change communication d. √ d. √ e. Voluntary counselling and testing e. e. √
44 f. Programme for sex workers f. √ f. √ g. Programme for men who have sex with men g. g. √ h. Programmes for injecting drug users, if applicable h. √ h. √ i. Programme for other most-at- risk population i. i. √ j. Blood safety j. √ j. √ k. Programme to prevent mother-to-child transmission of k. k. √ HIV l. Programme to ensure universal precautions in health l. √ l. √ care setting m. Other (Please specify) m. m.
, 2005 Poor Good 0 1 2 3 4 5 √√√ 7 8 9 10
2003 Poor Good 0 1 2 3 4 √√√ 6 7 8 9 10 In case of discrepancies between 2003 and 2005 rating, please provide main reasons supporting such differences.
45
, , , , , , ,
Yes No √ N/A
a. HIV screening and blood transfusion a. √ a. √ b. Universal precautions b. √ b. √ c. Treatment of opportunistic infections (OI) c. c. √ d. Antiretroviral therapy (ART) d. d. √ e. Nutritional Care e. e. f. Sexually transmitted infection care f. √ f. √ g. Family planning services g. g. h. Psychosocial support for people living with HIV and h. h. √ AIDS i. Home-based care i. i. √ j. Palliative care and treatment of common HIV/AIDS- j. √ j. √ related infections: pneumonia, oral thrush, vaginal candidiasis and pulmonary TB (DOTS) k. Cotrimoxazole prophylaxis among HIV – infected people k. k. l. Post exposure prophylaxis (e.g. occupational exposures l. l. to HIV, rape) m. Other (Please specify) m. m.
Comments:
, 2005 Poor Good 0 1 2 3 √ 4 5 6 7 8 9 10
2003 Poor Good 0 1 2 √ 3 4 5 6 7 8 9 10 In case of discrepancies between 2003 and 2005 rating, please provide main reasons supporting such differences.
3.1 IF YES , Is there an operational definition for orphans √√√
46
and other vulnerable children in the country?
IF YES , please provide definition ______
3.2 Which of the following activities have been implemented under orphan and vulnerable children programmes?
School fees for orphans and vulnerable children Community programmes Other (please specify)
Comments:
, 2005 Poor Good √√√ 1 2 3 4 5 6 7 8 9 10
2003 Poor Good √√√ 1 2 3 4 5 6 7 8 9 10 In case of discrepancies between 2003 and 2005 rating, please provide main reasons supporting such differences.
47
√√√ 1.1 IF YES, was it endorsed by key partners in evaluation ?
Comments: The development of M&E plan will be completed some time in 2006.
1.2 Was the Monitoring and Evaluation plan developed in consultation with civil society, people living with HIV?
a data collection and analysis strategy well defined standardized set of indicators guidelines on tools for data collection a strategy for assessing quality and accuracy of data a data dissemination and use strategy
3.1 IF YES, has funding been secured? √√√
√√√
IF YES, Based in NAC or equivalent? Based in Ministry of health? Elsewhere? Please specify
4.1 IF YES, are there mechanisms in place to ensure that all major implementing partners submit their reports to this Unit or Department?
Comments:
48
4.2 Is there a full-time officer responsible for monitoring and evaluation activities of the national programme?
Yes full time Yes part-time √√√
4.3 IF YES, Since when? Year ______
Yes regular Yes irregular √√√ Date last meeting
5.1 IF YES, are there mechanisms in place to ensure that all major implementing partners submit their reports to this Unit or Department?
√√√
(Low to High) , ,
0 1 2 3 4 5 6 √√√ 8 9 10
Comments: Most implementing agency share there monitoring and evaluation results, best practices and achievements.
√√√
8.1 IF YES, what type is it? ______
National level √√√ Sub national* (* Reporting regularly data from health facilities aggregated at district level and sent to national level, analysed, and used at different levels but HIV/AIDS related data is limited to HIV test, if available). NCASC however updates and circulate reported cases disaggregated by age, sex and risk group categories.
Comments:
49
National level √√√ Sub national* * If yes, please specify the level, i.e. district
,
√√√
Comments: Although there is no central M and E system in place, Monitoring and evaluation information shared by implementing agencies are used during planning and implementation
,
At national level? √√√ At sub national level? √√√ Including civil society? √√√
, 2005 Poor Good 0 1 2 √√√ 4 5 6 7 8 9 10
2003 Poor Good 0 1 2 √√√ 4 5 6 7 8 9 10 In case of discrepancies between 2003 and 2005 rating, please provide main reasons supporting such differences.
50
1. , , , ,
√√√
a) There is no specific provision in laws which protect against discrimination on the basis of HIV infection. However, Article 11 of the Constitution of the Kingdom of Nepal, 1990 has guaranteed fundamental right to equality, according to which all citizens are equal before law and no one shall be denied the equal protection of law. It prohibits discrimination against any citizen on the application of general laws on grounds of religion, race, sex, caste, tribe or ideological conviction or any of these. b) Article 12 (2) (e) of the Constitution guaranteed right to carry out profession of one's own choice to each citizen. Similarly, Section 6 (7) of the Civil Rights Act, 1955 also state that no discrimination shall be made on the ground of profession or business and one is entitled to carry out profession or business of his/her choice. c) Nepal has ratified/signed 16 international human rights instruments including UDHR, ICCPR, ICESCR, CEDAW, CRC, ICERD, which have adopted the principle of non-discrimination. Section 9 of the Nepal Treaty Act, 1991 has clearly mentioned that once ratified, the provisions of international instruments prevails as national laws and shall prevail over the domestic laws in so far as it conflicts with national laws. d) However, despite the constitutional guarantee against discrimination amongst citizens on grounds of religion, race, caste, tribe, ideological conviction or any of them and equal protection of law to all citizens, 17 in practice, there are some legal provisions which discriminate against persons suffering from infectious diseases, which may include HIV infected persons. The Infectious Disease Control Act has conferred powers on His Majesty's Government to issue any order on general people or a group of people in order to prevent transmission of and to cure infectious diseases. 18 It also provides that the infected person may be kept separately in any place or hospital and his/her movements may be controlled. 19
The Prison Act requires segregation of sick prisoners from the others. 20 Also, the Hotel Management and Liquor Sales and Distribution (Control) Act, 2023 (1967) prohibits the hotel entrepreneurs to provide accommodation to a person suffering from infectious diseases 21 Since these Acts does not clarify which diseases are included in the definition of
17 Article 11of the Constitution of the Kingdom of Nepal, 2047 (1990). 18 Section 2 (1) of the Infectious Diseases Control Act, 2020 (1963). 19 Section 2 (3) of the Infectious Diseases Control Act, 2020 (1963). 20 Section 6 (1) (e) of the Prison Act, 2019 (1962). 21 Section 5 (1) (b) of the Hotel Management and Liquor Sales and Distribution (Control) Act, 2023 (1967).
51
disease or infectious diseases, it is not clear whether persons suffering from HIV/AIDS may be segregated and kept separate under the order, however it is possible that the law may be used for this purpose.
Further, to get appointment in civil service or other government-controlled organizations and association one must submit medical certificate that s/he is of good health. 22
f) Regarding policies, the National Policy on AIDS and STD Control, 23 and Guide Book on HIV/AIDS Care and Prevention of the Nepal Medical Association 24 have adopted the policy of non-discrimination to the person living with HIV/AIDS. Also, human rights approaches for reducing stigma and discrimination against PLWHA is central guideline and principle of the National HIV/AIDS Strategy. 25 , , , , , ,
√√√
, a) The Constitution of the Kingdom of Nepal has provisions to take special measures for persons who are inter alia , physically or mentally disabled or are economically or socially or educationally backward. 26 This may includes vulnerable population to HIV and AIDS. b) In Sapana Pradhan Malla ’s case Supreme Court of Nepal stated that sex work is also like any other profession and no discrimination could be made on the basis of sex work. 27 c) However, there are no laws and regulations which has specific provisions for protections of the vulnerable population to HIV and AIDS discrimination 3.
22 Rule 58 of the Civil Service Regulation, 2050 (1993); Rule 220 of the Local Self-Governance Regulation, 2056 (1999), Rule 19 of the Health Services Regulation, 2055 (1998). 23 No. 1 (i) and No. 8 of the National Policy on AIDS and STD Control, 2052 (1995). 24 Objectives of the NMA Guide Book on HIV/AIDS Care and Prevention, Nepal Medical Association, Kathmandu, 2000. 25 National HIV/AIDS Strategy (2002–2006), Nepal, National Center for AIDS and STD Control, Ministry of Health, HMG/Nepal, 2002, p. 13. 26 Article 11 (3) of the Constitution of the Kingdom of Nepal, 2047 (1990).
27 Writ No. 56/2058, Date of decision: 2059.1.19 B.S. (May 2, 2002), Publication of Judgments relating to Human Rights (Special issue) Supreme Court 2059(2002), pp. 144-151
52
√√√
, : Supreme Court of Nepal has interpreted sex work as a profession and there is no specific laws that penalize sex work in Nepal. However, in the absence of special protection to sex workers, law dealing with public order and obscenity i.e. Some Public (Offence and Punishment) Act, 2028 (1971) is being used by police time and again to arrest, harass and prosecute sex workers. The harassment from the law enforcement agencies discourages sex workers to seek HIV prevention and care programs and therefore is an obstacle in HIV prevention and care for this group. Section 1 and 4 of the Chapter on Bestiality in the Country Code, 2020 (1963) prohibits acts of “unnatural sex”, with a provision for punishment of up to one-year imprisonment. It is assumed that the mentioned term “unnatural sex” also covers same sex relationship and can be used to prosecute men who have sex with men. Laws related with rape i.e. Chapter on Rape in the Country Code does not recognize that rape may occur to men. The Constitution of the Kingdom of Nepal prohibits discrimination among citizens on grounds of religion, race, sex, caste, tribe, or ideological conviction or any of these; however it doesn't specifically mention sexual orientation as a ground of non-discrimination. Also, Draft Penal Code, 2059 (2002) proposes penalizing consensual homosexual practice and proposes for up to 3 months imprisonment. There is no legal protection for the distribution of sterilized injecting equipments in the community. Further, the Ministry of Home Affairs has formally indicated that the act of distributing injecting equipments will be considered in breach of laws against drug use. Also, the draft of the Drug Policy is also not based on right-based approach and do not cover sterilized syringe exchange programme amongst drug users. Further, the Infectious Disease Control Act has conferred powers on His Majesty's Government to issue any order on general people or a group of people in order to prevent transmission of and to cure infectious diseases. 28 This provision may be used against any specific most-at-risk groups and therefore may affect effective HIV prevention and care.
√√√
:
28 Section 2 (1) of the Infectious Diseases Control Act, 2020 (1963).
53
The National Policy on AIDS and STD Control, 29 and Guide Book on HIV/AIDS Care and Prevention of the Nepal Medical Association 30 have adopted the policy of non-discrimination to the person suffering from HIV/AIDS. Also, human rights approaches for reducing stigma and discrimination against PLWHA is central guideline and principle of the National HIV/AIDS Strategy. 31 5. , ,
√√√
, Some of the groups are • Nepal plus • Nave Kiran • Prerana • Sahara Plus • Sneha Samuha
• Blue Diamond Society
• Recovering Nepal • Richmond Fellowship Nepal • KYC Punarjagaran Kendra • Youth Power Nepal The vulnerable groups were under one of the theme groups in the development of National HIV/AIDS Strategy. 32 Also, the participation of PLWHA was ensured in the development of the Strategy. The participation of “target groups” in the design and implementation of programmes and projects and the involvement of people living with HIV/AIDS in the design and implementation of policies, strategies, programmes and projects are incorporated as guiding principles in the National HIV/AIDS Strategy. 33 Financial: Also, the National Strategy in its guiding principles recognized that the resources allocation must take into consideration defined priorities based on the vulnerability of various affected groups and communities. 34
29 No. 1 (i) and No. 8 of the National Policy on AIDS and STD Control, 2052 (1995). 30 Objectives of the NMA Guide Book on HIV/AIDS Care and Prevention, Nepal Medical Association, Kathmandu, 2000. 31 National HIV/AIDS Strategy (2002 – 2006), Nepal, National Center for AIDS and STD Control, Ministry of Health, HMG/Nepal, 2002, p. 13. 32 National HIV/AIDS Strategy (2002-2006), 2003. Nepal: National Centre for AIDS and STD Control, Ministry of Health HMG/Nepal, p. 12.(English language version). 33 National HIV/AIDS Strategy (2002-2006), 2003. Nepal: National Centre for AIDS and STD Control, Ministry of Health HMG/Nepal, p. 16.(English language version). 34 National HIV/AIDS Strategy (2002-2006), 2003. Nepal: National Centre for AIDS and STD Control, Ministry of Health HMG/Nepal, p. 15.(English language version).
54
6. , ,
√√√
Guaranteeing equal access to basic care and services for all persons infected and affected by HIV/AIDS is one of the guiding principles of the National HIV/AIDS Strategy. Further, the guiding principles of the Strategy also recognized gender dimensions and states gender considerations to be central to the development of programmes and interventions.35 Also, the Strategy contains strategies to minimize mother to child transmission of HIV. 36 7.
√√√
: The National HIV/AIDS Strategy has no specific policies in regard to ensuring equal access to prevention and care for most-at-risk populations as ensuring care and support services to be available and accessible for all people infected and affected by HIV/AIDS is one of the priority areas of the Strategy. 37 However, within the developed strategies, the National Strategy specifically recognized the need for a focused care and support system to be gradually implemented amongst IDUs (and by association their partners) and to achieve an appropriate care and support system for HIV infected IDUs and their respective families (partners) is one of the objectives of the Strategy.38 Also, ensuring that prisoners living with HIV/AIDS have access to quality care and support is one of the strategies of the National HIV/AIDS Strategy. 39 8. , , ,
√√√
Although there is no legal provision specifically requiring HIV testing for appointment, promotion, training or other facilities for employees in government establishment, there is a mandatory provision requiring
35 National HIV/AIDS Strategy (2002-2006), 2003. Nepal: National Centre for AIDS and STD Control, Ministry of Health HMG/Nepal, p. 15.(English language version). 36 National HIV/AIDS Strategy (2002-2006), 2003. Nepal: National Centre for AIDS and STD Control, Ministry of Health HMG/Nepal, p. 38.(English language version). 37 National HIV/AIDS Strategy (2002-2006), 2003. Nepal: National Centre for AIDS and STD Control, Ministry of Health HMG/Nepal, p. 16.(English language version). 38 National HIV/AIDS Strategy (2002-2006), 2003. Nepal: National Centre for AIDS and STD Control, Ministry of Health HMG/Nepal, p. 22.(English language version). 39 National HIV/AIDS Strategy (2002-2006), 2003. Nepal: National Centre for AIDS and STD Control, Ministry of Health HMG/Nepal, p. 28.(English language version).
55
submission of certificate of heath stating that the employee is not suffering from serious or contagious disease before receiving a public appointment, including in the Civil Services. 40 However, the employee may be appointed if the certified doctor recommends that the candidate can carry out their prescribed functions. 41
In order to get new recruits in the Royal Nepalese Army, 42 Nepal Police 43 and Armed Police, 44 the candidate must be declared healthy after receiving health check-up carried out by the prescribed Medical Board or doctor. Any medical and physical disability is a ground for rejection.
Law does not require proof of good health for employment in the private sector; however, there are reported cases in which employers in the private sector refused employment to individuals known to be HIV-positive or required people to resign from their positions if the employer found out that they were HIV-positive. 45
9.
The National Ethical Guidelines for Health Research in Nepal, enacted as per the Nepal Health Research Council Act, 1991 has criteria for specific provisions related to ethical guidelines for health-related research in Nepal. The Guidelines have criteria for the research proposal,46 ongoing review of research, and termination or suspension of approved research. 47 The Guidelines have established an Ethical Review Board (ERB) in order to carry out these activities. 48 However, the Guidelines do not have any specific provisions with regard to HIV and AIDS research protocols involving human subjects. 9.1 ,
√√√
40 Rule 19 of the Civil Service Regulation, 2050 (1993). 41 Schedule 5 of the Civil Service Regulation, 2050 (1993), Schedule 7 of the Nepal Television By- Laws, 2055 (1998). 42 Rule 4 (c) of the Royal Nepalese Army Recruitment Rules, 2019 (1963); Rule 3 (f) of the Royal Nepalese Army Recruitment, Promotion and other various General Provisions Rules, 2020 (1964); Rule 5 (e) of the Army Legal Department (Recruitment, Promotion and Terms of Service) Rules, 2019 (1960); Rules 6 and 7 of Boys (Recruitment and Terms of Service) Rules, 2028 (1971). 43 Rule 13 (J) of the Police Regulation, 2049 (1992). 44 Rules 8 and 9 of the Armed Police Regulation, 2060 (2003). 45 HIV/AIDS and Human Rights: A Legislative Audit, 2004, Nepal: NCASC, POLICY Project/Nepal and FWLD, p. 44. 46 Such as minimization of risk of subject, informed consent, confidentiality, mechanism for compensation, and withdrawal from research at any time without fear of any action. 47 Such as suspension and termination of research work, if conducted against the ERB’s requirement, and possibilities of unexpected serious harm to participants. 48 Section B of the National Ethical Guidelines for Ethical Research in Nepal, Nepal Health Research Council, Kathmandu, 2001.
56
Ethical Review Board (ERB) formed by the guidelines includes member from civil society but does not includes people living with HIV and AIDS. 49 10. Does your country have the following monitoring and enforcement mechanisms? Collection of information on human rights and HIV No and AIDS issues and use of this information in policy (NCASC is performing the and programme development reform task, however the process is yet to be initiated at nationwide level) Existence of independent national institutions for the No promotion and protection of human rights, including (The Human Rights human rights commissions, law reform commissions Commission Act, 2053 and ombudspersons which consider HIV-and AIDS- (1996) has established a related issues within their work National Human Rights Commission to protect and promote human rights. The Commission has the mandate to work on all aspects of human rights, however it has just initiated to operate a section to deal with human rights violations in relation to HIV and AIDS. Establishment of focal points within governmental Yes No health and other departments to monitor HIV-related √√√ human rights abuses Development of performance indicators or Yes No benchmarks for compliance with human rights √√√ standards in the context of HIV and AIDS efforts
√√√
Legal aid systems for HIV No and AIDS casework (The Legal Aid Act, 2054 (1997) provides for general criteria of legal aid on the grounds of individual’s annual income. Also, there are provision of paid lawyer in the court and Nepal Bar Association are providing free legal aid to women and helpless persons,
49 Section B of the National Ethical Guidelines for Health Research in Nepal, Nepal Health Research Council, Kathmandu, 2001.
57
however there is no specific legal aid services in regard to HIV and AIDS casework from the government sector. Nonetheless civil society is providing free legal aid services to vulnerable communities and PLWHA. State support to private Yes No √√√ sector laws firms or university based centres to provide free pro bono legal services to people living with HIV and AIDS in areas such as discrimination Programmers to education, No raise awareness among National HIV/AIDS Strategy focuses people living with HIV and on educating and raising awareness AIDS concerning their amongst public and specific groups) rights.
13. Yes, reducing the stigma surrounding people living with HIV/AIDS is one of the priority objectives of the National HIV/AIDS Strategy 50 , , 2005 Poor Good 0 1 2 3 4 6 7 8 9 10 2003 Poor Good 0 1 2 4 5 6 7 8 9 10 In case of discrepancies between 2003 and 2005 rating, please provide main reasons supporting such difference : Programme expanded in 2005 including Global Fund and increased assistance from EDPs to reach more vulnerable people and policy makers than in earlier years. Workplace policy was also introduced
, , 2005 Poor Good 0 1 2 3 √√√ 5 6 7 8 9 10
2003 Poor Good 0 1 2 √√√ 4 5 6 7 8 9 10 In case of discrepancies between 2003 and 2005 rating, please provide main reasons supporting such differences.
50 National HIV/AIDS Strategy (2002-2006), 2003. Nepal: National Centre for AIDS and STD Control, Ministry of Health HMG/Nepal, p. 33.(English language version).
58
Annex 3: National return forms
1. Total no. of respondents tested for HIV 642 380 18 0 1040 2. Total no. of respondents who know the result 638 384 17 0 1039 3. Number of respondent tested for HIV and who know 1039 the results Total number of IDUs 19850
(Source: FHI/VCT centres programme report Nov2004-Oct 2005))
1. Total no. of respondents tested for HIV 504 430 934 2. Total no. of respondents who know the result 495 418 913 3. Number of respondent tested for HIV and who 495 418 913 know the results Total number of Sex workers 29750
(Source: FHI/VCT centres programme report Nov2004-Oct 2005))
1. Total no. of respondents tested for HIV 247 126 373 2. Total no. of respondents who know the result 244 125 369 3. Number of respondent tested for HIV and who 244 125 369 know the results Total number of Migrants 1249000
59
(Source: FHI/VCT centres programme report Nov2004-Oct 2005)) (Denominator source: FHI national size estimate)
1. Total no. of respondents tested for HIV 571 835 1406
2. Total no. of respondents who know the result 556 816 1372 3. Number of respondent tested for HIV and who 556 816 1372 know the results
Total number of Clients 659000
(Source: FHI/VCT centres programme report Nov2004-Oct 2005)) Denominator: FHI national estimate) 1. Total no. of respondents tested for HIV 25 28 53 2. Total no. of respondents who know the result 25 28 53 3. Number of respondent tested for HIV and who 25 28 know the results 53 Total number of MSM 128500
(Source: FHI IBBS 2005) Denominator: FHI national estimate)
, Number of respondents exposed to peer education 4374 4294 8668
Number of respondents exposed to targeted mass NA NA 0 media
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Number of respondents exposed to STI screening and 3075 5113 8188 treatment*** Number of respondents exposed to HIV counseling and 406 202 608 testing* Number of respondents exposed to substitution therapy - - 0 and safer injection practices for IDU.
Sources: FHI Programme Monitoring data [Oct '04 to sep '05] NCASC Jan 2005-Nov2005 and FHI as above
** National size estimate for FSW *** 40% adjustment made for double counting based on programme experiences
, Number of respondents exposed to peer education Number of respondents exposed to targeted mass media Number of respondents exposed to STI 11 11 22 screening and treatment* Number of respondents exposed to HIV 507 665 1172 counseling and testing** Number of respondents exposed to sub stitution therapy and safer injection practices for IDU.
FHI [#data collection period: Oct '04 to sep '05] ** NCASC
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, Number of respondents exposed to peer 0 education Number of respondents exposed to targeted 0 mass media Number of respondents exposed to STI 140 140 screening and treatment Number of respondents exposed to HIV 373 373 counseling and testing Number of respondents exposed to 0 substitution therapy and safer injection practices for IDU.
1249000
Source: FHI Programme Monitoring Data (Oct 2004 - Nov 2005)
, Number of respondents exposed to peer 4068 2678 6746 education Number of respondents exposed to targeted 0 mass media Number of respondents exposed to STI 70 51 121 screening and treatment Number of respondents e xposed to HIV 25 28 53 counseling and testing Number of respondents exposed to 0 substitution therapy and safer injection practices for IDU.
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128500
FHI Programme Monitoring data (Oct '04 to sep '05)
(IBBS FHI) 1. HIV can be avoided by having sex with only one faithful, uninfected partner 1076 240 1317 2. HIV can be avoided by using condom 1194 264 74 1362 3. A he althy looking person can have HIV/AIDS 0 238 68 1378 4. A person can get HIV from mosquito bite 752 149 26 640 5. A person can get HIV by sharing a meal with someone who is infected 1118 220 14 1041 6. Number of respondents giving the correct answ ers to all the above five questions 621 98 14 426
7. Number of respondents who gave answers (including "don't know") to all the above 5 questions or had never heard of AIDS 1245 358 83 1597
Indicator s core (line 6/line 7 x 100) (Source: Global Fund/New Era - Knowledge, Attitude and Practice in six GFATM districts 2005)
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Number of respondent who reported that a condom was used with their last client 318 129 366 160 209 400 1582 24 41
Number of respondents who reported having commercial sex in the last 12 months 600 200 400 200 300 656 2356 36 48
Kathmandu, Pokhara, eastern terai and western terai - IBBS 2005 Injected drugs sometime in the last month 590 643 1233 590 643 1233 Injecting drug users in the last month who avoided sharing injecting equipment in the last month 431 409 840 431 409 840 Injecting drug users in the l ast month who had sexual intercourse in the last month 234 352 586 234 352 586 Injecting drug users in the last month who avoided sharing injecting equipment but had sexual intercourse in the last month 146 235 381 146 235 381 Injecting drug users in the last month who used condoms during the most recent sexual intercourse (in the last month) 131 169 300 131 169 300 Injecting drug users in the last month who never shared injecting equipment and used condoms during the most recent sexual intercourse (in the last month) 80 122 202 80 122 202 80 122 202 80 122 202 Avoided sharing injecting drug equipment and either avoided having sex or used condoms during most recent sexual intercourse (all in the last month) (line 2 - line 3b + line 4b) 365 296 661 365 296 661
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234 352 586 (Source: IBBS IDUs 2005)
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Annex 4: Bibliography
1. ACR (2004), Peace and Governance Foundation South-Asia Partnership-Nepal, Posted on 2004-10-20 ACR Weekly Newsletter Vol. 3, No. 42 2. Bhattachan, K., Gautam, I. and Khadka, J. (1998). Impact of Migration on Children and Women: a Qualitative Study of Selected VDCs of Surkhet an Achham Districts . Kathmandu: Save the Children UK. 3. Cumulative HIV/AIDS Situation of Nepal, as of July 31, 2005, NCASC/MOH 4. http://www.the-south-asian.com/Jan%202004/aids_in_south_asia-2.htm 5. Nepal at a glance: YOUANDAIDS, UNDP, www.youandaids.org/Asia%Pacific/Nepal/index.asp 6. CARE (2004), A Pilot Initiative on Understanding People Living with HIV/AIDS and Exploring the Ways Forward for Their Support in Nepal, CARE Nepal Kathmandu, 7. Central Bureau of Statistics (2003). Population Monograph of Nepal. Volume II. Kathmandu: CBS 8. CWIN (2004). State of the rights of the child in Nepal 2004. Kathmandu: CWIN. 9. CREHPA/SACTS/FHI, IBBS study-2004 10. Currently available ANC prevalence rate is 0.2% from 1999 survey. Without reliable sentinel surveillance data available, and also considering high prevalence among sub- populations (migrants 10%, IDUs over 60%, FSWs in KTM 48%) estimated prevalence of 1% has been applied for the target number estimation. 11. DeCock, K., Fowler, M.G., Mercier, E. (2000): Prevention of mother-to-child transmission of HIV in resource poor countries. JAMA 283:1175-82 12. Elisabeth A. Preble (2004) PMTCT in Nepal, Situation Assessment and Recommendations, 2004 July, , MPH, Consultant, UNICEF/Nepal 13. Family Health Division (2002). Nepal Demographic and Health Survey 2001 . Kathmandu: Family Health Division, Department of Health Services, Ministry of Health, and New ERA, Kathmandu, and ORC Marco, Maryland, USA. 14. The implications of early marriage for HIV/AIDS policy, WHO/UNFPA/Population Council, 2004 15. Central Bureau of Statistics (2003). Population Monograph of Nepal. Volume II . Kathmandu: Central Bureau of Statistics. 16. FHI (2004). Behavioural and Sero-Prevalence Survey among Injecting Drug Users in Pokhara Valley, Nepal . Kathmandu: Family Health International (FHI), New ERA, National Centre for AIDS and STD Control (NCASC) and USAID. 17. FHI (2004). Injecting and Sexual Behaviours of Injecting Drug Users in Jhapa District, Nepal . Kathmandu: Family Health International (FHI) and Center for Research on Environment, Health and Population Activities (CREHPA). 18. FHI (2002). Behavioural and Sero-Prevalence Survey among Injecting Drug Users in Kathmandu . Kathmandu: Family Health International (FHI), and New ERA. 19. FHI (2004). Injecting and Sexual Behaviours of Injecting Drug Users in Biratnagar, Nepal . Kathmandu: Family Health International (FHI) and Center for Research on Environment, Health and Population Activities (CREHPA). 20. FHI (n.d.). Stigma and Discrimination in Nepal: Community Attitudes and the Forms and Consequences for People Living with HIV/AIDS . Kathmandu: Family Health International (FHI).
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21. FHI (2004), Women and HIV/AIDS: Experiences and Consequences of Stigma and Discrimination-Nepal 22. FHI/NEW ERA (2002 November) HIV/AIDS prevalence and risk factors among migrant and non-migrant males of Achham District in Far-Western Nepal (Volume -1 Main Text), Nepal 23. FHI, New ERA and SACTS, 1999 and 2003 24. FHI/New ERA, 2005 Integrated Bio-Behavioural Survey (IBBS) among Female Sex Workers in Kathmandu Valley 25. FHI (2004). STI/HIV Prevalence and Risk Behavioural Study among Female Sex Workers and Truckers along the Terai Highway Routes covering 22 Districts of Nepal . Kathmandu: FHI, New ERA and STD/AIDS Counselling and Training Services (SACTS). 26. FHI (2004). Focused Ethnographic Study of Risk Behaviour and Condom Use among Mobile and Static Female Sex Workers in Eastern Terai . Kathmandu: FHI and Center for Research on Environment, Health and Population Activities (CREHPA). 27. FHI (1999). STD and HIV Prevalence Survey among Female Sex Workers and Truckers on Highway Routes in the Terai, Nepal . Kathmandu: Family Health International (FHI). 28. FHI (2003) Assessment of Migration and Associated risk behaviour among Nepali Migrant Men in Mumbai. Kathmandu: FHI/USAID/Impact 29. Gilligan, B.J. and Rajbhandari, R. (2004). HIV/AIDS and Working Children in Nepal . Kathmandu: International Labour Office (ILO). 30. Gilligan, B.J. (2003). Child Labour in Nepal: Understanding and Confronting its Determinants . Kathmandu: ILO. 31. GEFONT/SARDI (2005), HIV/AIDS vulnerability assessment among Trade Unions, Kathmandu (Unpublished) 32. Global Fund (2003) Proposal rounds II. P.23. 33. Global Fund (2005), A report on baseline study for the benchmark of pre implementation situation of HIV/AIDS porgramme among migrant labourers and young people in six districts of Nepal, New Era, Kathmandu 34. Ministry of Health (1997). Nepal Family Health Survey 1996 . Kathmandu: Ministry of Health, New ERA, and Macro International, Maryland, USA. 35. NCASC (n.d./2005). Stigma and Discrimination in Health Settings in Nepal. Case Studies among Technical Health Workers, Non-Technical Health Workers and People Living with HIV/AIDS . Kathmandu: National Centre for AIDS and STD Control (NCASC). 36. NCASC/FHI (2003). National Estimates of Adult HIV Infections: Nepal, 2003 . Kathmandu: National Centre for AIDS and STD Control (NCASC) and Family Health International (FHI). 37. New ERA, SACTS and FHI, 2000. The 1 st round Integrated Bio-behavioral Survey (IBBS) among FSWs conducted in the16 Terai highway districts of Nepal. 38. New ERA (2003). Behavioural Surveillance Survey in the Highway Routes of Nepal: Round No. 5 . Kathmandu: New ERA and FHI. 39. New ERA (2003). Behavioural Surveillance Survey of Female Sex Workers and Clients in the Kathmandu Valley: Round 1. Kathmandu: New ERA and FHI. 40. New ERA/SACTS/FHI. STD and HIV prevalence SurveyAmong Female Sex Workers and Truckers on Highway Routes in the Terai, Nepal round 1 (1999) 41. New ERA/FHI. Behavioural Surveillance Survey in the Eastern to Western Highway Route of Nepal : Round No.1-5 (1998-2002) 42. Peace Women, Women's International League for Peace and Freedom CONFLICT FUELS HIV/AIDS CRISIS, by Kamala Sarup, http://www.nepalnews.com.np/contents/englishweekly/telegraph/2004/jul/jul28/views.htm
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43. PMTCT in Nepal, Situation Assessment and Recommendations, 2004 July, Elisabeth A. Preble, MPH, Consultant, UNICEF/Nepal 44. POLICY Project/USAID, Media Review: Analysis on Reporting of HIV/AIDS in Nepal, 2004 September (published by NCASC/POLICY and Sancharika Samuha). 45. PSI Nepal, Social Marketing Monthly Security Status (Management Information System), as of April 2005 46. South Asian Conference Capacity Building of Marginalized Women: Widow Conference Report-II, Plenary-Day 1 -International Testimony of Widows, 1st-3rd February 2002, New Delhi 47. A joint NCASC/HMG, USAID, FHI, DFID and UNAIDS Collaboration (2004). HIV/AIDS Treatment, Care and Support in Nepal, National Rollout Plan October 2004-September 2005, Kathmandu 48. (source: GFTAM prop. P.23. 2001 New Era study). 49. Nepal/India Safe Migration Initiative (Reducing HIV risk among Nepali migrants to Mumbai, USAID Discussion paper, Draft Feb.2004. 50. GFTAM prop. P.23 - CBS 1999, DFID, 2000 51. News: Young Nepali tells how he was forced into 'sexual slavery' in India and life in a brothel, By Sunil B. Pant (in Kathmandu) and Andy Harley 6 April 2005, http://archives.healthdev.net/sex-work/msg00581.html 52. Norwegian Refugee Council (2004). Nepal: up to 200,000 people displaced by fighting remain largely unassisted. Geneva Switzerland 53. Pant, S. (2001). Report on the First Outreach Training Workshop for Men who have Sex with Men in Nepal . Kathmandu: Blue Diamond Society. 54. Pokharel, B. et al. (2000). Situation Analysis of HIV/AIDS in Nepal . Kathmandu. 55. Puri, M. (2001). Sexual Risk Behaviour and Risk Perception of Unwanted Pregnancies and Sexually Transmitted Diseases among Young Factory Workers in Nepal . Kathmandu: CREHPA. 56. USAID (2004). Assessment of Youth Reproductive Health/HIV Programs in Nepal . Kathmandu: USAID. 57. UNICEF (2002). The Increasing Vulnerability of Children in Nepal. An Assessment of Children and Families Affected by HIV/AIDS and the Response at Family, Community, District and National Levels . Kathmandu : UNICEF. 58. Peace and Governance Foundation South-Asia Partnership-Nepal , Posted on 2004-10- 20 ACR Weekly Newsletter Vol. 3, No. 42 59. UNAIDS/NCASC (2004). The HIV/AIDS/STD Situation and the National Response in Nepal: Country Report . Kathmandu: UNAIDS and National Centre for AIDS and STD Control (NCASC). 60. Puri, M. (2001). Sexual Risk Behaviour and Risk Perception of Unwanted Pregnancies and Sexually Transmitted Diseases among Young Factory Workers in Nepal . Kathmandu: CREHPA. 61. UNAIDS/New ERA survey 2005 62. UNAIDS/NCASC (2004). The HIV/AIDS/STD Situation and the National Response in Nepal: Country Report . Kathmandu: UNAIDS and National Centre for AIDS and STD Control (NCASC). 63. UNDP (2004). Human Development Report 2004 . New York: UNDP. 64. UNICEF (2001), A Survey of Teenagers in Nepal for Life Skills Development and HIV/AIDS Prevention. Kathmandu: UNICEF and UNAIDS. 65. UNICEF ROSA. A Force for Change: Young People and HIV/AIDS in South Asia. Kathmandu: UNICEF Regional Office for South Asia.
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66. UNICEF (2003). Evaluation of United Nations-supported pilot projects for the prevention of mother-to-child transmission of HIV. 67. UNICEF/NCASC (2004). PMTCT in Nepal, Rapid Assessment Report. Kathmandu 68. USAID (Draft Feb.2004) Nepal/India Safe Migration Initiative, Reducing HIV risk among Nepali migrants to Mumbai, Discussion paper 69. USAID (2004). Assessment of Youth Reproductive Health/HIV Programs in Nepal . Kathmandu: USAID. 70. WHO (2003). HIV/AIDS Work Plan for 2004–2005 Nepal. Kathmandu: Nepal 71. MOH (2003), National Health Sector Programme – Implementation Plan NHSP-IP, Ministry of Health and population, Kathmandu 72. Norwegian Refugee Council Nepal (2004): up to 200,000 people displaced by fighting remain largely unassisted. Geneva Switzerland 73. World Bank Nepal (2004), Costing of the Nepal Health Sector Program-Implementation Plan with Unit Cost of Essential Health Care Services (EHCS) as cited in NHSP-IP 74. UNESCO/CREHPA (November 2005) A study on Knowledge, attitude practice and belief in the context of HIV/AIDS among out of school Street based children in Kathmandu and Pokhara
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Annex 5: Programme framework
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Annex 6: List of contributors
The list of those who actively participated at the different stages of the report writing process is as follows:
Deependra Khaniya Programme/ Producer Agni Ojha Communication Corner, Programme Assistant Hamro Rhiya Club SPARSA Nepal Kopundole, Lalitpur Chovar Gate, Kathmandu Dilli Ram Tiwari Anjan AmatyaAdvisor Secretary National Association of People Living PRERANA Gairidhara with HIV (NAP+N) Bansbari Dr Ram Prasad Shrestha Medicare National Hospital Anupama Shrestha Chabahil Programme Manager Himalayan Social Welfare Dr. M. P Shrestha Organization Deputy Executive Director Nepal Pulchowk, Fertility Care Centre Kupondole, Lalitpur Arun Timilsina Youth and HIV/AIDS Coordinator Dr. Nirmal Prasad Pandey NTUC Director Centre for Policy Research and Ashok Karki Analysis (CRPA) Nepal Red Cross Society Sano Gaucharan, Gyaneshwor, Kalimati, Kathmandu Kathmandu
Ashok Pandey Dr. Ranga R. Dhungana Director Health Care Coordinator HASTI-AIDS Pro-public Anamnagar, Kathmandu Bijulibazaar, Kathmandu
Basundhara Adhikari Ekta Mahat Sneha Samaj Recovering Nepal Balkhu Lazimpat
Bishnu Lamsal Hari Lamsal GEFONT Democratic Confederation of Nepalese Putalisadak Trade Union (DECONT) Bishnu Sharma Baneshwor, Kathmandu Programme Coordinator Richmond Fellowship Nepal Hari Prasad Awasthi Kathmandu President NANGAN Chiranjivi Khanal Bijuli Bazaar, Kathmandu Training Director Nepal Press Institute Babar Mahal
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Ishwor Shreshta Federation of Nepalese Chamber of Rajiv Kafle Commerce and Industries Coordinator (FNCCI) Navakiran Plus Teku, Kathmandu Dhapashi
Jagadish Chandra Bhatta Member Secretary Ramesh Khanal NANGAN YPN Bijuli Bazar, Kathmandu Kathmandu
Jeevan Bista Rishi Ojha Media Home Dillibazar, President Kathmandu Nepal Harm Reduction Council Anamnagar Kathmandu Kalpana Bhattarai Antena Foundation Kopundole Rojee Khadki President Khumanand Subedi Sahara Plus Executive Director Pulchowk SISo-Nepal New Baneshwor, Kathmandu Rup Narayan Shrestha Advocate Manish Gautam FWLD Senior Correspondent Thapathali Samaya Weekly Sharad Rajopadhyay Narayan Kaji Shrestha DIC in charge Women Acting Together for Change Siddhi Memorial Foundation (WATCH) Bhaktapur Battisputali, Kathmandu Shikha Sharma Narendra Mishra Assistant Programme / Producer Samjhauta Nepal Communication Corner, Hamro Rhiya Koteshwor, Kathamndu Club Kopundole, Lalitpur Niranjan Dhungel Research Officer Shyam Sundar Baskota New Era Business Manager Kalopool, Kathmandu Sakriya Sewa Samaj Thapathali, Noor Jung Shah Associate Director Sunil Babu Pant General Welfare Pratisthan President Gyaneshwor, Kathmandu Blue Diamond Society Lazimpat, Kathmandu Pooja Niraula Coordinator Tulasa Lata Amatya Richmond Fellowship Nepal Programme Manager Jawalakhel Community Action Center Bansbari Prakash Chandra Ghimire NEFSADA Kathmandu
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Urmila Bista Save the Children (Norway) NHF Kathmandu Nepal Accham Nirmal Rijal Usha Titikshu Country Manager Civic Society for Peace Equal Access Nepal Kupondole, Lalitpur Prem Subba World Vision International Asha Lal Tamang Kathmandu Britain Nepal Medical Trust Lazimpat, Kathmandu Radhika Ghimire World Vision International Bhojraj Pokhrel Kathmandu Country DirectorPolicy Project Nepal Rajan Man Shrestha Save the Children US Bina Pokhrel Maharajgunj Technical Adviser Policy Project Nepal Pulchowk Jhabindra Bhandari Bir Bahadur Lama Programme Officer - Health Sector AADRA JICA Kathmandu Pulchowk
Chakra Bahadur Bhandari Shanta Gurung Family Planning Association Nepal United States agency for International Pulchwok Development (USAID) Rabi Bhawan, Kathmandu Darinji Sherpa United Mission to Nepal Sharon Ascott-Mills Thapathali Senior Technical Adviser United States agency for International Dr Saroj Ojha Development (USAID) General Secretary Rabi Bhawan, Kathmandu AMDA Dr. Laxmi Bilas Acharya Team Leader, SRM Anjani Kumar Pokhrel Family Health International DYSP Gairidhara Armed Police Force Halchowk, Kathmandu Dr. Linda Caringal United Mission to Nepal Bharat Mani Pandey Thapathali Section Officer Ministry of Local Development Jacqueline Mcpherson Sri Mahal, Pulchowk Deputy Director Family Health International (FHI) Bharati Adhikari Gairidhara, Kathmandu Section Officer Ministry of Health and Population Kalu Singh Karki Programme Officer
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Dr Pulkit Choudhury Senior Medical Officer NCASC Dr Amaya Maw Naing STP WHO Dr. Megh Gurung UN House Senior Superintendent of Police Police Hospital Maharajgunj Dr. Sathyanarayan Doraiswamy Health and Nutrition Co-ordinator Dr. Sashi Sharma M.D. UNHCR Damak Sub-Office Associate Professor, Jhapa Depart of Medicine T.U Teaching Hospital Leela Raj Upadhyay Maharajgunj, Kathmandu National Programme Officer World Food Programme Chakupat, Lok Nath Gautam Patan Ministry of Health and Population RamShahpath Mala Rai HR Assistant Madhuri Rana World Food Programme Section Officer Chakupat, Patan Ministry of Women, Children and Social Welfare Manju Karki Singha Durbar, Kathmandu HIV/AIDS Project Officer UNFPA UN House Pulchowk Mathbar Adhikary Under Secretary Ministry of Home Pragya shah Affairs Programme communication and Singha Durbar, Kathmandu Information officer Global Fund HIV/AIDS PMUUNDP UN Prem Kumar Shahi House, SSP Pulchowk Armed Police Force Halchowk, Kathmandu Rajan Bhattarai WHO UN House Revati Raj Kafle Joint Secretary Rojee Kattel National Planning Commission Communication and Public Specialist Singha Durbar, Kathmandu Decentralized Local Governance Support Programme (DLGSP) Samir Kharel Bakhundole, Lalitpur Inspector Nepal Police Headquarter Naxal Ms. Aurorita Mendoza Ms. Narmada Acharya Mr. Mahesh Sharma Mr. Robert Thomas Mr. Jagadish Dhakal Mr. Pawan Joshi Ms. Smriti Aryal Dr. Khem Karki Mr. Sheldon Allen, report editor
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