University of Huddersfield Repository Karki, Sangeeta Risks and Vulnerability to HIV, STIs and AIDS Among Street Children in Nepal: Public Health Approach Original Citation Karki, Sangeeta (2013) Risks and Vulnerability to HIV, STIs and AIDS Among Street Children in Nepal: Public Health Approach. Post-Doctoral thesis, University of Huddersfield. This version is available at http://eprints.hud.ac.uk/id/eprint/21282/ The University Repository is a digital collection of the research output of the University, available on Open Access. Copyright and Moral Rights for the items on this site are retained by the individual author and/or other copyright owners. 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The author of this thesis (including any appendices and/or schedules to this thesis) owns any copyright in it (the “Copyright”) and she has given The University of Huddersfield the right to use such Copyright for any administrative, promotional, educational and/or teaching purposes. ii. Copies of this thesis, either in full or in extracts, may be made only in accordance with the regulations of the University Library. Details of these regulations may be obtained from the Librarian. This page must form part of any such copies made. iii. The ownership of any patents, designs, trademarks and any and all other intellectual property rights except for the Copyright (the “Intellectual Property Rights”) and any reproductions of copyright works, for example graphs and tables (“Reproductions”), which may be described in this thesis, may not be owned by the author and may be owned by third parties. Such Intellectual Property Rights and Reproductions cannot and must not be made available for use without the prior written permission of the owner(s) of the relevant Intellectual Property Rights and/or Reproductions. 1 DECLARATION “I hereby declare that this submission is my own work and that, to the best of my knowledge and belief, it contains no material previously published or written by another person nor material which to a substantial extent has been accepted for the award of any other degree or diploma of the university or other institute of higher learning, except where due acknowledgment has been made in the text.” 2 ACKNOWLEDGEMENTS First and foremost I must remember to thank God for this PhD endeavour, for giving me the strength and for making this all possible. My utmost gratitude extends to my principal supervisor Prof. Adele Jones, whose continuous encouragement, guidance and unfailing support made this journey easier, which is unforgettable. Her valuable time and advice tirelessly and intelligently guided me towards the successful accomplishment of this study. Many thanks Prof. Adele; I will forever be thankful to you. I am also very grateful to my associate supervisor Prof. Ruth Deery for her advice and comments, which shaped and influenced my thinking. I would like to extend my sincere acknowledgements to staff members in the department for their support: Kirsty Thomson and Alison Holmes for their administrative support; they always stood by our side for our needs. I would also like to thank Professor Eric Blyth and Dr. Bernard Gallagher for their insightful discussions. I would like to note my appreciation of my colleague, Kusnadi, who is a wonderful friend and who has been supportive and encouraging from the beginning. I extend thanks to Christine Piper for her support, which is appreciated. Especial thanks to Limota and Sajida for their friendship, and for being helpful in different ways. I am glad to have interacted with Ena, Gloria, Deborah, Eric and Maud, who were genuinely nice. I thank Maggie Mundy for helping me quickly proof read my work and for her suggestions in editing my work. I am thankful to my father Nani Ram Karki, my mother Saraswati Karki and my brother Sanjaya Karki for their good wishes and encouragement. I also express my sincere gratitude to my husband Prakash Singh Deuja for the support and generosity he sustained throughout the study. He often listened to me and responded when the times were rough and through the highs and lows. My soul as always reaches to my daughter Saibasri Singh Deuja. I do apologise for the inconvenience caused to you when I was away during the study period. 3 ABSTRACT Street children are a population highly at risk of HIV/AIDS/STIs, which is becoming an overriding concern. Due to the critical importance of the problem under investigation, this study focuses on the causes and consequences of risks involved in the dynamics of HIV/STIs transmission and the occurrence of AIDS. The study utilised a qualitative paradigm, with two methods of data collection from children and young people in the street; these were observation and in-depth interviews, which emerged as the most appropriate methods for investigating the HIV/AIDS risks and vulnerability of street children. The study was guided throughout by a public health theoretical framework. The study revealed that children leave home due to parental mistreatment; they engage in risky sexual behaviour living in the street, they have little or no understanding of HIV, AIDS and STIs or of the respective relationship between these, and they have negative attitudes towards HIV/ STIs treatment and people affected by HIV/AIDS. Four domains of HIV/STIs and AIDS risks and vulnerability of street children were identified: parental mistreatment (causing vulnerability to exposure and thus the likelihood of acquiring HIV and STIs); high risk-taking sexual behaviour (creating vulnerability to infection); lack of knowledge regarding HIV, AIDS and STIs (vulnerability to re-infection); negative attitudes towards HIV/STIs treatment and people affected by HIV/AIDS (resulting in denial, failure to seek treatment and contributing to the perpetuation of the problem); and the effects of living in the street (increasing vulnerability to progression from HIV to AIDS). By exploring the prime and subsequent root risk factors, these complex interlinking risks have been analytically conceptualised, providing a model which explicates the complete phenomenon of risks and vulnerability to HIV/STIs and AIDS for street children, as well as for broader society, in a cyclical manner. Hence, HIV/STIs and AIDS is not a health problem among street children only, it is a public health problem in the broader society in Nepal. Having identified these problems for street children, this study offers an intervention plan, the CAP model. This model extends previous public health approaches and argues for targeted action to prevent risk and vulnerability for children in the street, and suggestions for policy and legislation which would enable the implementation of the model are offered. 4 GLOSSARY OF ACRONYMS ADB Asian Development Bank AIDS Acquired Immune Deficiency Syndrome APC Association for the Protection of Children CBS Central Bureau of Statistics CPCS Child Protection Centres and Services CWCN Child Watabaran Centre Nepal CWIN Child Workers in Nepal Concerned Centre GDP Gross Domestic Product HIV Human Immunodeficiency Virus IDUs Intravenous Drug User/s ILO International Labour Organization MSM Men who have Sex with Men NCASC National Centre for AIDS and STD Control NDHS Nepal Demography and Health Survey SAARC South Asian Association for Regional Cooperation STD Sexually Transmitted Disease STI/s Sexually Transmitted Infection/s UNAIDS The joint United Nations Program on HIV/AIDS UNCRC United Nations international Convention on the Rights of the Child UNESCO United Nations Educational Scientific Cultural Organization UNICEF United National International Children and Emergency Found US United States USAID United States Agency for International Development VCT Voluntary Counselling and Testing WHO World Health Organization 5 TABLE OF CONTENTS COPYRIGHT STATEMENT .......................................................................................... 1 DECLARATION ............................................................................................................... 2 ACKNOWLEDGEMENTS .............................................................................................. 3 ABSTRACT ....................................................................................................................... 4 GLOSSARY OF ACRONYMS ........................................................................................ 5 TABLE OF CONTENTS .................................................................................................. 6 LIST OF FIGURES ......................................................................................................... 13 LIST OF TABLES ..........................................................................................................