Ensnared by AIDS. David K. Beine

fourth wave has begun; as of 2010, housewives of these men have become the single largest group accounting for nearly 45 percent of all new infections (Sarkar 2010). This assertion is confirmed by the estimates given in figure 3.1. It is also likely, given the numbers of HIV positive children reported (1,372 in fig. 3.3) and estimated (3,804 in fig. 3.1), that the final fifth wave (noted by Smith above) is also well underway in Nepal.

      Although these types of epidemiological studies are a crucial part of a deeper understanding of the complexities of HIV and AIDS in Nepal, they often ignore the complex social issues involved in the spread of the disease. These issues will be the focus of the remainder of this chapter.

3.2 Nepali HIV and AIDS literature

      The HIV and AIDS literature reviewed from Nepal generally falls into three broad categories: strict bio-medical and epidemiological profiles (e.g., those from which the above data is derived), literature that focuses primarily on the structural factors contributing to the HIV and AIDS problem in Nepal, and literature that focuses mainly on aspects of individual agency or various cultural traditions. Factors in each of these categories contribute to the spread of HIV and AIDS in Nepal. I have already addressed the epidemiological literature. In this section I will focus on the literature which addresses the social side of HIV and AIDS in Nepal. In each section I will first address the early years of the epidemic and then address the newer literature.

      3.2.1 Structural issues

      The dominant discourse in Nepal during the early years of the epidemic (and still a prevailing discourse today) goes something like this: Commercial sex work has been identified as the main route through which HIV infection has entered the general population (Cox and Suvedi 1994; New Era 1997; Sattar 1996). This happened through three main channels: (1) Nepali women are “trafficked” to India (usually Bombay) where they work as FSWs for some years.56 Then, either after “retiring” or being repatriated for being HIV positive (Dixit 1996:52; Smith 1996:10), they return to their homeland of Nepal, where they continue to work, thus spreading the AIDS virus to the remotest corners of Nepal (Sattar 1996). (2) Nepali men in search of work migrate in large numbers to India and further abroad where they subsequently obtain the services of HIV-infected FSWs (Cox and Suvedi 1994; Smith 1996). They then return home, transmitting the virus to their unsuspecting wives, who subsequently pass the virus to their unborn children (Poudel 1994). (3) Truck drivers and soldiers are well known for their promiscuity and preference for unprotected sex (Sattar 1996). These factors, coupled with the transient nature of their occupations, make soldiers and truck drivers natural conduits for the spread of HIV and AIDS along the roads and trails and into the remotest corners of Nepal.

      Because commercial sex work has been identified as a primary factor in the spread of AIDS in Nepal, the discourse on HIV and AIDS has subsequently been subsumed within the wider discourse of commercial sex work and other related discourses such as “girl trafficking.” Those analyzing the issue of HIV and AIDS in Nepal from a critical medical anthropology (CMA) perspective or a political economy medical anthropology (PEMA) perspective, tend to focus on the underlying causes of commercial sex work in Nepal. Prostitution and occupational migration are viewed as the result of deeper economic and political problems. David Seddon, for instance, suggests:

      There has been, and remains, a tendency...to focus attention on women, both as sources of infection (prostitutes) and as the main victims. While understandable, this tends to result in an under emphasis of other factors which contribute to the spread of infection and the development of the epidemic. The economic and social pressures which force women into prostitution, and men to make use of commercial sexual services, and the economic rewards which lead men to organize the sex trade as a source of profit, also need to be analyzed and understood. (Seddon 1995:4)

      So, for Seddon, the root of the problem of HIV and AIDS is not commercial sex work, rather it is the economic and social pressures which push women into this profession, and which push men abroad where they are vulnerable to the use of commercial sexual services.

      Likewise, Meena Poudel (1994:10–11) suggests that rural women are the most adversely effected by poverty in Nepal and that poverty is, in turn, “the principle cause of the greater risk of HIV infection in Nepal.” Poverty, according to Poudel, is mainly a result of “resources being whittled away by multi-national companies” that leads women to pursue prostitution because of a lack of viable alternatives. Poudel claims that “the main reason for this situation among women can be ascribed to widespread poverty, low status, lack of decision making rights, lack of access to time for education and information, rural-urban imbalances, inability to assert their rights, and so on” (1995:11).

      Dixit (1996:50) also reflects this political economy approach when he concludes that in Nepal, “poverty is the root cause of the problem of AIDS,” and that prostitution and migration, “two processes that expose the Nepali population to the HIV virus,” are “the result of an attempt at poverty alleviation.”

      Another study of STD and HIV infection among prostitutes in Calcutta (based on self-reporting) found that extreme poverty, illiteracy and family disturbances were among the factors most responsible for leading FSWs into prostitution (Chakraborty et al. 1994:165).57 The authors claim that economic necessity was the most important reason for entry into prostitution and that “illiteracy was probably the main reason why they could not struggle to find some other means of livelihood and resorted to sex trade as the best alternative.” Again, economic necessity is stressed as the structural factor contributing most greatly to the spread of HIV and AIDS. Various other authors who note poverty as a key factor strongly linked to the spread of HIV and AIDS in Nepal are Sattar (1996), Keyser (1993), Nigam (1994), Smith (1996), Dixit (1996), and Suvedi, Baker and Thapa (1994). And more recent studies on HIV and AIDS in Nepal continue to address the epidemic from this perspective (e.g., Poudel and Carryer 2000, Sarkar et al. 2008, Rodrigo and Rajapakse 2010).

      Although a CMA or PEMA perspective is useful and adds another dimension to the earlier epidemiological perspective, this structural approach tends to ignore the agency of the individual in making his or her own decisions. For instance, in the Calcutta survey (Chakraborty et al. 1994), the authors found that 39 percent of the women who had turned to prostitution claim they did so of their own volition, yet they don’t address this issue anywhere in their findings. The focus of the article is only upon the structural factors influencing the 61 percent who claim to have been forced into prostitution through economic necessity. In a study of 289 FSWs in Nepal, 66.7 percent cited “necessity” while 21.4 percent cited “pleasure” as their reason for entering the sex trade (Karki, Geurma, and Suvedi 1995). Although 51 percent of FSWs in another study (Bhatta et al. 1994) listed “economic hardship” as their main motivation for entry into the sex trade, “enjoyment,” “separation from husband” or “husband’s long absence from home,” and “husband’s polygamy” were other reasons given. In a third study of FSWs in Pokhara, Nepal, the authors found that many women self report that they have chosen this profession of their own volition. The authors quote one woman as saying:

      I do not care what people say but I am happy to be earning money in such an easy way. I can feed my child, have a place to live, eat good food, wear good clothes, move around in taxis... it gives me great relaxation when I have sex! Any ways nobody will give me any other job and I do not want my child and myself to starve. I saw my friends earning and I did not find it wrong and I started working too. (Baral 1999)

      I imagine many CMA or PEMA advocates would argue that these women’s own words do not fully represent the “whole picture” (and they are right). It is clear, however, that in some cases, individuals can and do (at least in part) manipulate the system, and this perspective is completely absent in the CMA or PEMA analysis of the HIV and AIDS situation in Nepal. Poverty certainly explains why many women enter the sex trade, but it does not explain why all do so. A study from 2008 (Sarkar et al.) might provide a healthy middle ground between these two seemingly polar positions. In this study the authors note that 68 percent had joined prostitution “voluntarily” (meaning that they were not “trafficked” in the traditional sense), thus, they had exercised a degree of personal agency in their decision to become a CSW, but perhaps they had done so ultimately for structural reasons (i.e., poverty).

      Migration has also been a factor identified