World AIDS Day (WAD) is celebrated every year on the 1st of December and is an opportunity for people worldwide, to unite in the fight against HIV, to show support for people living with HIV, and to commemorate those who have died from an AIDS-related illness. Founded in 1988, World AIDS Day was the first ever global health day and one of the eight official global public health campaigns marked by the World Health Organization (WHO).
The theme for this year’s WAD is, “Increasing Impact through Transparency, Accountability, and Partnerships”. This theme reflects the United States government’s longstanding leadership in addressing HIV/AIDS both at home and abroad and how they are increasing their impact to move epidemics from crisis toward control.
As reported by UNAIDS, globally, there were 36.7 million people living with HIV in 2016. Amongst them, 2.1 million are children less than 15 years old. In 2016, 1.8 million people were newly infected with HIV and 1 million people died from AIDS-related illnesses. As of June 2017, there are 20.9 million people accessing antiretroviral therapy worldwide.
Among the South Asian Countries, the prevalence rate is highest in India followed by Nepal. There are two major types of HIV causing infections in humans, HIV-1 and HIV-2. The majority of infections in South Asia is caused by HIV-1. However, there are confirmed cases of HIV-2 infection in India and Nepal.
In Nepal, the first case of HIV was recorded in 1988. According to the recent data from National Centre for AIDS and STD Control (NCASC) as of July 2017, there are a total of 30,200 cases of HIV/AIDS. Amongst them, males comprise of 62.07 percent, females comprise of 37.5 percent and transgender comprise of 0.003 percent of the total cases. Currently, 19,388 people with HIV are receiving ART services.
In recent times, 13,000 people have been estimated to be newly infected, a sharp drop from the previous years.
According to the National HIV Estimates, NCASC (National Centre for AIDS and STD Control)2016, the estimated adult HIV prevalence is 0.17 whereas the HIV incidence per 1000 population is 0.03%.
There are 32,735 people living with HIV. Amongst them, males comprise of 61.8% whereas females comprise of 38.2%. The estimated number of new infections in 2016 was 942, which shows a declining trend than the previous decade. The annual number of AIDS related deaths are 1,771 which shows a slight decline than the previous years.
In Nepal, there are various groups of people who are at higher risk of becoming infected with HIV. They are people who inject drugs, sex workers and their clients, men who have sex with men, trans- genders, labour migrants and their wives as well as prison inmates.
Nepal Demographic Health Survey 2016 shows that 81 % of women and 98% of men aged 15-49 years are aware of AIDS. Among women, knowledge of AIDS is higher in urban areas (85%) than in rural areas (72%). Specifically, men are more aware than women that HIV can be transmitted from mother to child during pregnancy (85% versus 73%), during delivery (74% versus 67%), and through breastfeeding (58% versus 53%), while women are more aware that the risk of transmission can be reduced by the mother taking special drugs (44% versus 36%).
Efforts from the government sector
For the prevention of people from HIV/ AIDS as well as to reduce the infection rate and its’ social, economic and development impact, National Policy on AIDS and STD Control, l995 (2052 BS) was implemented for the first time in Nepal, one and half decades ago. In line with this, Nepal launched the first National AIDS Prevention and Control Program, established a multi‐sector National AIDS Coordinating Committee (NACC) in 1992 followed by establishment of National AIDS Council (NAC) in 2002 to raise the profile of HIV/AIDS. The National Centre for AIDS and STD Control Centre (NCASC) under the Ministry of Health is the main body for implementing all activities related to HIV & STD prevention and control throughout the country.
In 2016, at the United Nations General Assembly, a High- Level Meeting was organized focusing on ending the AIDS epidemic. Nepal also participated and reaffirmed its commitment to Fast –Tracking its HIV response as per the global call. NCASC envisions ending HIV/AIDS as a public health threat by 2030. To fulfill this vision, the government launched its National HIV Strategic Plan “NHSP 2016-2021: Nepal HIVision 2020” on 1 December, 2016. This strategy aims to achieve the 90-90-90 treatment targets for 2020 whereby 90 percent of all those living with HIV will know their HIV status, 90 percent of those living with HIV will receive antiretroviral therapy and 90 percent of those receiving antiretroviral therapy will have suppressed viral loads. Recently, the GoN has also developed a “National HIV testing and treatment guideline 2017” which supports the Test, Treat and Retain continuum, based on the "WHO Consolidated Guidelines on the use of Antiretroviral Drugs for treating and preventing HIV infection".
HIV services available in the public sector include HIV testing, services for sexually transmitted infections, antiretroviral therapy, and elimination of vertical transmission and screening of donated blood. An HIV recording and reporting system has been integrated into the health management information system. Anti-retro viral treatment (ART) services was first started through Shukraraj Tropical and Infectious Diseases Hospital, Kathmandu from February 2004 and the expansion of freely available ART services has resulted in substantial reduction in AIDS related diseases in Nepal. Currently, ART services are being provided from 68 sites among which 12 sites are in Eastern Region, 19 sites are in the Central Region, 16 in the Western region, 10 in Mid-Western region and 11 in Far Western Region. Tests to measure the number of CD4 cells are being provided by 27 centers. Likewise, there are 263 HIV testing and counselling centers throughout the country.
To combat and address HIV/AIDs, currently almost 100 NGOs are in work and along with that, numerous private and voluntary organizations implement activities funded by donors. NGOs and INGOs such as AHF Nepal, Water Aid Nepal, Action Aid International Nepal, TPO Nepal, UNESCO Nepal, Maiti Nepal, PHASE Nepal, Heal Nepal etc. are working for the prevention of AIDS in Nepal. USAID’s HIV and AIDS program has been on the forefront of the global AIDS crisis for 30 years.
4C’s of preventive mechanisms
We talked to Dr. Chandani Kharel, MD Dermatology &STD specialist on her views regarding AIDs and the efforts made by the government in addressing the issue of AIDs and STDs as a whole.
The term sexually transmitted diseases (STDs) refers to a variety of clinical syndromes and infections caused by pathogens that can be acquired and transmitted through sexual activity. STDs are broadly categorized into ulcerative and non- ulcerative types. The ulcerative type of STD increases the risk of acquiring HIV as having a sore or break in the skin from an STD may allow HIV to more easily enter the body. People with STI have three-ten times greater risk of being infected with HIV. In a single sex act, the STI can increase HIV risk from 1: 1,000 to more than 1:10.
As the behaviors and risk factors for getting HIV & STD are similar, being infected with one disease might put an individual at higher risk for getting the other. Having anal, vaginal, oral sex without a condom or having multiple or anonymous sex partners increases the risk for both STDs and HIV. The high-risk population are mostly female sex workers and their clients, men who have sex with men and trans-genders. Thus for reducing one’s chances of getting such disease, one should use condoms consistently and correctly. Similarly, choosing less risky sexual behavior and reducing the number of people with whom you have sex results in lower chances of getting STDs and HIV.
While talking about the efforts placed from the governmental sector, National Centre for AIDS and STD Control under the Ministry of Health has developed the National Guideline on Cases Management of Sexually Transmitted Infections (STIs) which is intended for use in any setting in Nepal by health care providers (HCPs). This guideline enables health care workers to provide effective treatment and obtain cure; treat asymptomatic patients and/or subclinical infections; prevent or reduce future risk-taking behavior; and to ensure that the sexual partners are appropriately traced and treated. All patients who come to seek treatment for STDs are screened for HIV.
On the other hand, health care providers give emphasis on the 4C’s for preventive mechanisms namely:
Compliance: Ensuring adherence to treatment and completion of treatment
Counseling/Client education: Providing information about the diagnosis and treatment of the disease as well as educating the client about risk factors associated with STDs and HIV/AIDS
Contact tracing/partner treatment: Making sure that all the partners are traced and encouraged to get treatment
Condoms: Promoting and providing condoms, and ensuring availability of condoms.
With the efforts from government as well as non-government sector, Nepal has, to some extent, seen positive changes in the situation of HIV/ AIDS. Figures do show decrease in the numbers of HIV cases as well as increase in knowledge level regarding HIV/AIDS, its transmission and preventive measures. There is 82% reduction in new HIV infections over the past decade as data shows that there were 7400 new HIV infections in 2001 as compared to 1300 in 2015. Even though this change is encouraging, Nepal still needs to increase its activities to curb the problem of HIV/AIDS. Along with preventive measures, there is a need to increase access to ART services. There is a dire need of coherence among the NGOs and development partners for a joint effort against HIV. Efforts need to be made for addressing the vulnerable groups mainly the sex workers and drug users. The social stigma attached to HIV/AIDS is predominant in our community and has been a major barrier in utilization of services and thus the eradication of stigmas and discrimination attached to AIDS remains a major step stone that we need to pass. For a HIV free generation, there is an utmost need of enhanced efforts from the government, non-government and private sectors to provide preventive and accessible curative services to all the Nepali people.
Contributors: Aanchal Parajuli and Swopnil Devkota