UNGASS National Report: Nepal 2005 I. STATUS AT A GLANCE National Commitment & Action 2 1. Government funds allocated for MSMs HIV/AIDS US$ 146,657 [MoHP] 1. Kathmandu 33.6% 3 2. National Composite Policy Index Migrants 93% Annex 2 4 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 National Programmes 1 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 Knowledge & Behaviour 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 . Impact 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 1 UNGASS National Report: Nepal 2005 II. INTRODUCTION 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. UNGASS areas of commitment (2001): 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 concentrated epidemic 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 core indicators 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. 2 UNGASS National Report: Nepal 2005 III. OVERVIEW OF THE AIDS EPIDEMIC The HIV/AIDS situation in the Kingdom of Nepal has been categorised as a concentrated epidemic . 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 country’s vulnerability to HIV and AIDS 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 projecting the course and impact of epidemic 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 nature of Nepal’s HIV epidemic 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 low-prevalence among the general population – based on seroprevalence studies of ANC (0.7%, 2005) and blood donors (0.29%, Kathmandu, 2005). As of December 2005, the Ministry of HIV transmission and prevalence in Nepal 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. 3 UNGASS National Report: Nepal 2005 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 increasing prevalence among higher risk groups 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 more cases reported among men (3 men for every woman, NCASC, 2006) and more cases reported in the Central Region and in urbanized areas and districts where migrant labour is more common . Accurate estimates of the rural-urban ratios are yet to be determined, but prevalence rates for rural districts are varied. Table 1: Summary of the epidemiological situation in Nepal Data Date 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).