Why Nepal's women are more prone to AIDS

By, America Chronicle, March 20, 2008

The rising trend of HIV/AIDS infections among Nepali women is suddenly being discussed at emergency levels by various international development agencies after their plight has been highlighted in the international media. Often Nepali health experts blame the AIDS rise on gender, sexual discrimination, and the lack of enough awareness on availability of safe reproductive health choices for Nepali women, an their poor knowledge based on AIDS prevention. According to UNAIDS Nepal statistics, as of 2006-2007, the coverage of HIV services for people most at risk was 15% for harm reduction; 22% for men who have sex with men; 68% for female sex workers; 27.5% for migrant laborers; 6% for personnel of the uniformed services; 4.5% for antiretroviral therapy; and 82% for prevention of mother-to-child transmission.

Women as an HIV/AIDS core prevention target however are found neglected purely on the basis of their silence. In Nepal, women contribute to 60% of national agriculture yield, have less than one-half access to incomes for the same category of jobs than men, work longer hours and produce nearly 55% of the national per capita income yield.

In 2008, primary AIDS service barriers to helping Nepali women include an inadequacy of public health infrastructure (facilities and logistics system), lack of female personnel trained in HIV services outside urban district headquarters and in critical areas where high-risk behaviors are prevalent; limited capacities of nongovernmental organizations for scale-up; and, fear of stigma and discrimination at health facilities.

Although Nepal´s Ministry of Health and Population has adopted a policy of decentralization of resources to capacitate district-level services, these efforts still lack core mainstreaming as an overall health intervention among donors and government counterparts. A whole big bureaucratic mess surrounds systematic referral service of women with HIV/AIDS and STIs in the rural areas. Due to these factors, AIDS mainstreaming into non-health ministries is limited, the education and labour implications are not considered, and there is parallel donor programming which makes them compete among themselves rather than work with one unified purpose.

In fact, UNAIDS Nepal Country Office stated recently that its overall effort in mainstreaming HIV/AIDS and targeting Nepali women with special programs was hampered by the April 2006 Jan Andolan which brought about a new government and several changes in the MOHP setup.

Overall, it appears in 2008, that Nepal has failed in properly integrating HIV interventions and services into other health components, though many agencies are expanding pilot efforts in HIV and sexual and reproductive health integration. According to UNAIDS, in 2008, tuberculosis and HIV units in various health institutions are working more closely together, while the World Bank has re-tailored the majority of its program outputs to adjust to rural demands for AIDS prevention and knowledge building services. More linkages definitely need to be created between key strategic communications and behavior change interlinkages so that various AIDS affected target groups can interact more openly among themselves as well as with the Ministry of Health and Population at the central and district level.

How can the Nepali problem be solved when it comes to giving women better HIV/AIDS treatment, care and support? It is felt by most donors that the low and inequitable coverage of HIV prevention and services must be reversed and a more equitable distribution network developed. Currently, only a fraction of Nepali women at high risk have access to AIDS prevention services in Nepal. Similarly, coverage must expand to provide more adequate VCT sites, solve resource constraints in antiretroviral drugs disbursement, develop timely logistical correction in drugs distribution taking into consideration geographical inaccessibility, and infuse proper distribution of brochures and other information and communication material in the Nepali and other local languages, that appears lacking. AIDS interventions, in short, must be gender specific in Nepal's context.

Nepal already faces increased levels of HIV infection among excluded populations and people exposed to HIV. The Nepal government's estimated number of people living with HIV is around 75,000, which comprised 0.5% of the 15 to 49 age group. However the Ministry of Health and Population is more comfortable quoting the 90,000 benchmark that other donors use, considering it a more realistic estimate. Taking the older figure of 75,000 AIDS infected, Nepali women comprise around 16,000 cases. Official deaths registered so far due to AIDS are around 5,100. There are nearly 2,500 AIDS cases identified among children under 16 in various hospitals in 2007. But Nepali epidemiologists and health experts believe the figure could be at least four to five times higher if every woman returning from India particularly those engaged in the commercial sex trade took an AIDS test in a nearby VCT. In other words, expect nearly 15,000 deaths every year for the next half decade due to HIV/AIDS infection in Nepal until figures stabilize due to current interventions as the curve stabilizes at some point in 5-7 years!


Nepali women have had to face the majority of infections because they happen to be the weaker sex, subjugated and dominated in the overall Nepali gender context. The number of migrant workers working in India, particularly in Mumbai, New Delhi, Bangalore and Kolkata has intensified. Nearly 8 million Nepali migrants live in India now, and at least one-sixth that number is known to visit their relatives and families' back home each year during the Hindu Dashain festival. Similarly nearly 100,000 Nepali women out of nearly 250,000 Nepali female commercial sex workers working in the major Indian cities have returned to Nepal in the past decade, of which nearly 40% are estimated to be HIV positive according to a 2003 BBC special report estimate. The trafficking of young women and children to India goes unabated despite stringent cross-border monitoring, and their ages range from 12-29 years old. Middle men charge anywhere between US$ 40 to US$ 600 to sell young Nepali women and girls to Indian brothels.

Similarly, many civil conflict displaced women and children, particularly those who have lost their husbands, or been driven away due to poverty in their homes and villages, have also no alternative but to migrate to the bigger cities and serve in various Nepali tea stalls, massage parlours, cabin restaurants and hotels. Some end up as maids but still low paid. In fact, the entire 28 KM ring road that circulates Kathmandu and Patan is full of cabin restaurants and cheap hotels meant for truck drivers and migrant communities from surrounding towns and villages around Kathmandu valley that come to sell vegetables and other raw commodties. International aid agencies working in HIV/AIDS impact mitigation believe that nearly 60,000 Nepali commercial sex workers are serving in these venues, all of them women employed in meager wages that range less than $3-5 a day.

After the Nepali civil conflict ended in 2006, some of the above detail slowly started surfacing and international donors started acting faster focusing on post-conflict rehabilitation and recovery efforts with some acknowledgment of the problem. While focusing on humanitarian interventions, they started focusing on Nepal, but with a 'Bangladesh in the 70s slant'. In short, Nepal became to many donors a new humanitarian and human crises zone, but where AIDS held sway over the country´s destiny in some undefined manner. This is the simple emerging truth of Nepal, its open border system, and the resulting increased feminization of HIV/AIDS cases.

In 2008 and the oncoming period, what Nepal needs is a high level of political commitment to get itself out of this unanticipated health rout. Instead of opting for fragmented and short term program outputs, Nepal must opt for a high level AIDS interventions, political commitment and visible national strategy solely concentrated in containing the feminization of the flow and defeating AIDS. HIV/AIDS must now be mainstreamed into Nepali society no doubt.

It is known that Nepal´s Prime Minister Girija Prasad Koirala is very much concerned with the health and education situation of most Nepali and he has repeatedly stated in the recent past, that these ought to be the national priorities, not politics. Despite, battling AIDS is not a national priority in the Nepali development agenda, though it is now acknowledged by the National Planning Commission as an acceptable crisis that needs some sort of socio-political intervention. It is imperative donors concentrate more on HIV prevention education for children, women, young people and young adults than spend endless sums of money in traditional capacity building activities of Nepal Government, where usually civil servants go abroad for a week or two on educational trips and come back with little experience to share at the national scale.

Advocacy, behavior change communications interventions must similarly be tailored to engage a strategic information parley with the infected population, particularly women, not trying to impose donor values and judgments that might be rejected as non-cultural specific, but knowledge transfer that includes cultural transformation. Service delivery must focus on prevention of mother-to-child transmission, harm reduction among drug users and joint national program management and support.

Above all there must be stronger civil society leadership, prioritization of workable strategies, strengthening data uniformity and relevance, monitoring and evaluation of all major government and donor activities, and systematizing technical support to government by the implementing partners aimed at technical soundness. Young people must be involved in reproductive health choices, enhancing life skills-based HIV education, and technical guidance on how to bear more successful results from the gender angle. These might be some, not an exclusive list of solutions, that might work best in Nepal´s context, based on the current weaknesses exhibited in fighting HIV/AIDS at the national level.

Source: http://www.americanchronicle.com/articles/55967