Ensnared by AIDS. David K. Beine

      Figure 3.2. 2012 Estimated HIV infections in Nepal: Part two.

      Figure 3.3. 2012 Cumulative HIV and AIDS infection reported in Nepal.

      According to the estimated figures (fig. 3.1), just over fifty thousand persons are thought to currently be living with HIV in Nepal (0.3% prevalence among the general population). Of this number, 86 percent (43,239) are estimated to be adults aged fifteen to forty-nine, 8 percent (3,804) children aged zero to fourteen, and 6 percent (3,244) adults over fifty. According to these estimates, heterosexual transmission is still the dominant form of HIV transmission and HIV infection rates remain at “concentrated epidemic” levels among several high-risk populations, such as injecting drug users (IDU), men who have sex with men (MSM), female sex workers (FSWs), clients of female sex workers and seasonal migrant laborers. The NCASC concludes that “further intensifying the effective targeted interventions for high risk groups with improved coverage is critical to contain the epidemic among high risk groups and to prevent spread into large general low risk population” (NCASC 2012a). Likewise, USAID claims that due to targeted prevention interventions among these key population groups, new infections rates have decreased significantly over the past five years and that Nepal is “on track” to achieve the sixth Millennium Development Goal.52 They acknowledge, however, that “it is critical to improve coverage in order for HIV and AIDS programs to reach the national target of halving new HIV infections by 2015. In addition, despite continuous efforts to combat stigma and discrimination, such barriers have remained major impediments to open access to information and services”(USAID 2013a).

      According to the reported figures (fig. 3.2), the numbers for the same period are less than half of the estimated number. Interestingly there is clear continuity (and even verbatim language) between the National Center estimated statistics (figs. 3.1 and 3.2) and UNICEF, UNAIDS, USAIDS, and WHO estimates. The “HIV epidemic update of Nepal,” provided by the National Center, cites “NCASC 2011” and “NCASC 2012” for its data, but there is no explanation about how the National Center derives their estimates. It is hard to tell whether these organizations mentioned earlier get their estimates from the National Center or vice versa? As one who has studied HIV and AIDS in Nepal for well over a decade, I am always mystified as to how these estimated numbers are derived.53

      To be fair, it has always been difficult to accurately assess HIV numbers in Nepal. In the early years of the epidemic, reporting of AIDS was thought to be very low (Suvedi 1998:53). At that time, Dixit (1996:46) concluded that “there can be no doubt that there have been deaths in Nepal from AIDS which were not recognized” and that “there are probably people ill with AIDS today whose condition has not been diagnosed.” Often times, people died in a village and the actual cause of death was never actually determined. Also, because of the nature of AIDS, often the cause of death was reported (if at all) simply as an opportunistic infection and no association with AIDS was ever made. In most places in Nepal, HIV tests were then unavailable. Even if they were available, many were not interested in determining if they were HIV positive, either because of lack of awareness about HIV, prohibitive cost involved in getting such a test, or desire to avoid the social stigma then attached to HIV positive persons in Nepal. Measuring prevalence (known as “sentinel surveillance”) was initiated among the general public but was far from successful due to various logistical problems (Maskey 1998). And today many of these factors still prevent accurate counting. According to the Director of the NCASC, the biggest barrier to accurate numbers today is that little headway has been made in testing (Sharma 2010). Dr. Rai admits that Nepal still “lags behind” in identifying infected cases who remain “hidden” in “fear of exposing themselves to the public” and concedes “the unidentified infected cases are exactly the reason why Nepal will not be able to meet the Millennium Development Goal (MDG) of halting and reversing the spread of HIV and AIDS by 2015” (Sharma 2010). So while various international agencies working from estimated numbers are touting Nepal’s success for meeting their goals, given the real numbers and the concessions by those leading the efforts in Nepal, it makes one wonder how we can be so certain of the progress?

      Despite the discrepancy between estimated and reported numbers there are a few epidemiological “facts” that seem certain. By 1998, HIV infection had been reported in fifty-eight of Nepal’s seventy-five districts and the main concentration of cases was in the central and eastern regions, namely, the capital and surroundings areas (Suvedi 1998:54). Early studies focused mainly on high prevalence rates which had reached and surpassed “concentrated epidemic” levels among those practicing high risk behaviors in the city regions. Several authors presented papers concerning HIV prevalence among these various groups at the Second National Conference on AIDS held in Kathmandu in 1998. Shrestha and Gurubacharya (1998) found the prevalence of HIV among female sex workers (FSWs) in the capital city to be 20 percent. In another study, Gurubacharya (1998) found the prevalence rate among non-migratory FSWs in Kathmandu had increased from 0.66 percent to 8.66 percent over a three-year period. The significance of this second study is that it was limited only to FSWs who had never been to India, thus suggesting that HIV infection had moved into, and for the first time was being spread by, the local FSW population rather than being limited to those coming from the outside.54 Among injecting drug users (IDUs) the prevalence rate was found to be 48 percent (Shrestha 1998). Interestingly, these earliest studies seem to be the basis for much “recirculation” of data that continues to be cited (as “current estimates”) throughout the most current literature.55 Since the publication of these original articles, it would appear that there has been a dearth of primary biomedical studies on these topics and some follow up studies are needed for comparative purposes. Once again, estimates can be deceiving.

      In recent years, the epidemiology of HIV in Nepal has begun to shift. HIV has now been detected in all regions of Nepal (Sharma 2008) and the largest numbers of HIV sufferers are to be found in the west and midwest of Nepal where out-migration rates are the highest. Male migrant laborers and their wives now make up the largest group of infected persons. According to Dr Krishna Kumar Rai, Director of the NCASC, by 2010 this group made up 45 percent of the total number of infected persons (Sharma 2010). Further, Rai admitted that by that same year prevalence rates in the midwest and far west regions had reached “generalized epidemic” levels with between 2–3 percent of the region’s population infected with HIV (Sharma 2010). So while it is difficult to discern between the rhetoric of estimated and reported numbers it would appear that there is still work to be done.

      There have been four proposed worldwide patterns of HIV spread. According to Gurubacharya (1996), in pattern one countries, HIV spread mainly among homosexual males and IDUs beginning in the late 1970s and early 1980s. This is the main pattern initially identified in the United States, Europe, Canada and Australia. In pattern two countries, HIV affected the general population beginning about the same time period, but mainly spread heterosexually and in the prenatal period. This is the main pattern found in sub-Saharan Africa, Latin America, and the Caribbean. Pattern three, identified as beginning in the late 1980’s, is characterized by HIV infection generally being “contained” within “high risk groups” such as FSWs and IDUs. This is the main pattern identified in Asia, Eastern Europe, some Pacific countries and the Middle East. In the mid 1990s a fourth pattern (pattern four) was proposed for parts of Asia (Brown and Xenos 1994). Pattern four is comprised of five waves of infection. The first of these was among homosexual or bi-sexual men having contact with foreigners. The second wave was among IDUs. The third was among FSWs and their clients. The fourth wave was among the girlfriends and wives of the FSW clients. And the final wave was among the children of these women. Smith (1996:8) suggests that this new pattern most closely fits (with a few modifications) the situation in Nepal.

      Dixit (1996:15) reported that the first wave of HIV and AIDS in Nepal was among Western tourists and FSWs returning from India. The second wave spread to the clients of these FSWs (the largest group being truck drivers and soldiers), mainly Nepali men, and to the population (many who were concurrently clients of FSWs) and spread rapidly among this mostly male population. Since then, the third wave, which began in the early 2000s, dominated with the highest numbers of HIV cases among migrant males, who have been