Nepal's National Center for AIDS and STD Control has received support from WHO, UNAIDS, UNDP, and USAID. But it lacks substantive funding to complete the necessary studies and interventions that are the key to HIV control. National efforts aimed at awareness of HIV are complicated by the ethnic diversity of Nepal, where some 75 different ethnic groups exist, speaking more than 50 languages.
A network of about 1,600 NGOs is now working on HIV/AIDS in Nepal. Local organisations are doing their best to reach out to those living with HIV/AIDS, but due to the urban-centric nature of most funding, funds available for the rural areas are scarce. Most donor representatives lack direct knowledge of the rural areas and rely on the instructions provided by NGOs in Kathmandu to dispense funds.
Foreign aid, which accounts for nearly 60% of Nepal's development budget, may have paradoxically contributed to lopsided development in Nepal. While aid money has favoured urban development and centralized power, the rural–urban gap has widened over the years. In Nepal, weak linkages between urban and rural areas, and lack of roads, communications, infrastructure, and appropriate skills among the rural poor mean that this urban bias has led to centralization of effective power on the one hand and maintenance of the economic, social, and political status quo on the other [30
]. Urban biases inevitably play a deterrent role, discouraging poor patients from seeking help. The poor see very little of the aid money, since most of it is used for prevention, information, and awareness in urban centres rather than for care and support in rural areas.
In our experience, some donors consider HIV care and support to be too expensive to fund, arguing that Nepal lacks the kind of infrastructure—clinics, district hospitals, and distribution units—needed to provide effective antiretroviral treatment, and that antiretrovirals are a priority only in countries with a high prevalence of HIV/AIDS (1% or more) in the general population [31
Harm-reduction interventions have been shown to slow the course of HIV among intravenous drug users (IDUs) in many developed countries [32
], but in Nepal the concept of harm reduction is still new. Few harm-reduction programs are government-supported or integrated into mainstream service delivery. Organisations such as the Lifesaving and Lifegiving Society, a street-based NGO established in Nepal in 1991, have been providing education, counselling, and primary health care—as well as bleach, sterile water, condoms, and new needles and syringes—to IDUs to lower their risk of acquiring blood-borne diseases [33
]. The prevalence of HIV infection among IDUs who were in regular contact with the program from 1991 to 1994 was low, at 1.6% [33
However successful, these programs have not reached the border zones with India where HIV infection has risen dramatically among IDUs. This dramatic rise is not surprising since research has shown that cross-border drug-use patterns in areas of Nepal bordering India are particularly conducive to risky needle sharing [34
]. Unlike IDUs in other Nepalese towns, very few of the IDUs in border towns belong to stable “injecting groups.” Sharing of contaminated injecting equipment in border towns is widespread, in part because of the makeshift arrangements in which the cross-border injecting takes place. Users often share their small amounts of money to buy drugs. Sexual intercourse with casual partners occurs, with inconsistent condom use [34
]. Effective intervention would therefore require complex cross-border collaborative efforts [34
People living with HIV/AIDS are stigmatized and face discrimination at all societal levels—in the community, at health facilities, and, most importantly, within the family [35
]. In a recent survey by CARE-Nepal, almost half of those who came to the voluntary counselling and testing centre at the Doti District Hospital in Silgadhi, a conflict-affected area, during June–July 2004 tested positive for HIV, and almost all of those tested positive were widows in their twenties and thirties [35
]. About 60% of them were breast-feeding their infants. These young widows faced rejection from their families, discrimination at work, and difficulty in coping with their life circumstances [35
One important development in recent years has been within the area of condom promotion for HIV/AIDS prevention. A national research study found that 76.6% of retail outlets surveyed had never sold a condom in 2002 [36
]. Population Services International began a national condom promotion program in early 2002 [37
] using a three-pronged approach: (1) a national media campaign promoting condoms (); (2) increased widespread condom availability within the private sector to destigmatize condom use; and (3) targeted condom promotion to high-risk groups such as sex workers [38
]. The impact of such efforts on condom sales has been dramatic. Total sale of condoms jumped from 11.9 million units in 2002 to 23.1 million units in 2004, and sales continue to climb [39
]. Creating long-term behaviour change and making condoms accessible in the private sector and affordable through subsidy to high-risk groups such as female sex workers appears to be increasing the uptake of condoms in Nepal.
Advertisement for “Number One” Condoms Marketed in Nepal by Population Services International