Nepal is going through a historic transition. A country that opened up to the West only in 1951, is also home to nearly 90,000  AIDS cases in 2008, which is still a guess estimate, since many epidemiologists believe the figure could be three times as big.  The country  has already lost 13, 600 lives to a devastating civil conflict which tore down the Nepalese  rural infrastructure between 1996-2006, although Nepalese are  now enjoying  more relative peace after the Maoists and the government came to the peace table.  While tourism is up 40% compared to last year, Nepal has not woken up as much to globalization like neighboring India or China. But international development experts believe, it should. According to Nepalese health planners, based on present AIDS  rate projections, the country  will be witnessing nearly 15,000 deaths every year for the next couple of  years, until  the AIDS rate finally stabilizes through  international interventions. 

Nepal received US$ 76 million from the UN’s Global Fund in 2007, but till now, there has been very poor coordination effort between the  UN and other international development agencies involved in direct HIV/AIDS impact mitigation. The projected AIDS deaths are considered by some too alarming n ratio in comparison to Nepal’s past civil conflict and current resource humanitarian aid  resource crunch.  The UN’s aids coordination in Nepal is chaired by a young Japanese lady who has shown much devotion to the cause.  Junko Sazaki, Chair of the UN Theme Group on HIV/AIDS and UNFPA Representative to Nepal often speaks passionately on the need to curtail promiscuous sexual behavior, introduce behavior change interventions, promote abstention measures and   draw on local best practices focusing on the A.B.Cs. But this is not happening as planned; the country’s politicians are concentrated  in fighting among themselves and preparing for a Constituently Assembly election on April 10, 2008.  They have little time to canvass on behalf of AIDS activists like Junko. 

Nepalese Prime Minister Girija Prasad Koirala has repeated on several important occasions in recent past, after reading international articles highlighting the plight of Nepalese women trafficking and AIDS, that Nepal’s two major priorities should be  health and education, not politics.  Nepalese and Indian authorities have also recently promised to step up efforts in cross border trafficking of young Nepalese girls and women aged 12-29 to Indian cities for commercial sex and prostitution. However, the traffickers still manage to find their way through the porous Indo-Nepalese border. 

UNAIDS  in Nepal  has been focusing on a national response coordinated by the National Center for AIDS and STD Control, a department under the Ministry of Health and Population whose majority activities are dependent on outside donors.  The department has a shabby, ghostly appearance with files thrown all over the floor and  its staff  busy attending various seminars and workshops. Many AIDS sufferers wish they were attended to instead.  Mr. Rajiv Kafle, a leading AIDS activist in Nepal has been outright critical of the government’s performance and feels there is room for a major shake-up. He had earlier expressed the view that AIDS interventions should not be bureaucratized.  

UNAIDS has been trying hard to fulfill its Nepali promise along with some positively minded donors such as USAID,  DFID and JAICA. An informal multisectoral stakeholders’ forum is in existence to develop and monitor progress of various partners. The UN  in Nepal just got a   new Resident Coordinator, the action oriented Robert Piper. Many are already counting on him to turn the situation around  though he has just been in Kathmandu for a week.   While UNAIDS claims that major progress is being made in harmonized planning among donors, it is not reflected in the National Action Plan,  which is considered incomplete by ministry officials. The National AIDS Council in Nepal is highly inactive due to political changes, and the National AIDS Coordination Committee has not been an effective mechanism for interventions either.  “Maybe we should get Ms. Jena Bush to Nepal to patch up things here”, some prominent women AIDS activists   lamented on World AIDS Day 2007 in Kathmandu.  The  World Bank and UNAIDS Country Office are discussing with the government how best to set up a quick intervention system, but it takes time in  dreamy Kathmandu to transform talk into real doable actions. Donor  tie-ups are only the starting point. 

Past Nepalese political instability has resulted in poor government support for the national AIDS control program, both financially and politically. According to a Nepali working with one of the donors, “Our national civil unrest had deepened the scenario of vulnerability, with growing numbers of mobile populations (internal and external labour migrants, and displaced people) and of young female sex workers. The current post-conflict phase has created a different nature of instability (an interim government and ethnic unrest) and a priority on peace building. According to UNAIDS, as of 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. Primary obstacles facing Nepal are related to service provision such as  inadequacy of public health infrastructure (facilities and logistics system) and lack of 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; fear of stigma and discrimination at health facilities, and lack of Ministry of Health and Population resource decentralization. 

In Nepal, AIDS mainstreaming into non-health ministries is limited according to UNAIDS. The main challenges for containing HIV/AIDS in Nepal are  to develop equitable coverage of HIV prevention and services; expand  services sites, address resource constraints for antiretroviral drugs and spread out interventions so that it is  geographically accessible to the  ones desiring service.  According to the UNDP website You and AIDS, Nepal hardly has the resources to fight the disease. The sad part of the story is that the larger percentage of deaths in future are going to be Nepali women, who account for nearly 60% of Nepal’s labour force in the agricultural sector and 100% of  those trafficked to India illegally.        

In South Asia, Nepal certainly tops in the number of returning commercial female sex workers infected with AIDS in 2008. The ground reality is that nearly 10,000 Nepalese women are being trafficked to Indian cities  annually, nearly 100,000 Nepalese women have returned back from Mumbai, of whom, BBC guess estimated in 2003 that nearly 40% had contracted HIV.     Nearly  half  the  women are married to Nepali husbands,  and  the remaining  are working in Kathmandu and  other Nepali urban  towns  in massage parlours,  cabin restaurants,  lodges, hotels,  dance restaurants,  Bhattis (drinking spots) and  road side restaurants on highways. The total number of Nepali commercial sex workers, all of them female, is nearly 250,000 in India’s major cities and many more infected with HIV will come back to Nepal once they cannot physically cope with infection.  Something must be done for them urgently. 

Overall, there has been an all encompassing concern among NGOs to trace the HIV infections’ diffusion by numbers, but despite it has been a beleaguering experience. Increasing HIV infection rates among young women is a matter of great concern both to India and Nepal, since it involves the sexually active people as low as 12 -29 years of age and India has nearly 2.3 million AIDS cases, though manageable through its excellent in-built health system and proxy drugs available. There are also other concerns such as young Nepali women and girls being made more vulnerable to infection by physiological and social factors resulting in the increasing feminization of the Nepali epidemic. Nepali women and young girls are  certainly considered facing the number one threat from HIV/AIDS infection in the South Asian region.

If  Nepal is going to overcome the feminization of  AIDS and  lessen its impact on the female sex,  new innovative thinking is required since past efforts have not fully borne good results, despite  concentrated donor funding. While there is the notion that appropriate behavior change education combined with strict penalties for those trafficking women might help, other opinions hinge on adding stronger political commitment,  poverty alleviation  measures,  building relationship between AIDS and tourism, industry and agricultural sectors, and providing more efficient treatment, counseling and home based care facilities. There is also the growing recognition that intervening stakeholders need to  address HIV/AIDS interventions through multi-sectoral, harmonized, coordinated actions in order to promote common holistic solutions for which the Nepal Government must take the pro-active initiative.  Less talk and more work as they say at PEPFAR.  Now it appears, Nepalese women’s AIDS pains need to be focused at the global level before their numbers become too big and spill over to the rest  of  South Asia.

(The author contributes regularly to  Nepal Horizons from Maryland, USA as well as serves as Regional Contributor to the American Chronicle National Media Network, Los Angeles. He is also a contributing  Google Global News Discussant Expert on international affairs, development; HIV/AIDS impact mitigation, US and Asia-Pacific immigration, gender and global climate change).

(Note from the Nepal Horizons Editorial Team: The views and opinion expressed in this article are that of the author and not of NHC. We request individuals with interest in Nepal to submit their views on contemporary Nepalese issues to the following e-mail address: editor@nepalhorizons.com.  Pictures of contributors or images that relate to submissions are welcome)