"EPIDEMIOLOGICAL ANALYSIS OF HIV AIDS IN THE CONTEXT OF NEPAL

SUBMITTED TO: Department of Public Health Faculty of Medical Sciences Nobel College Sinamangal, kathmandu Pokhara University

SUBMITTED BY: Anurag Sedai(04) Bipin Adhikari(12) Deepika Paudel(15) Pranita Sharma(24) Supriya wagle(37) GROUP "D"

BPH 2nd SEMESTER SUBMITTED ON: 9th September, 2009

ACKNOWLEDGEMENT
We are privileged on receiving this opportunity to prepare term paper on EPIDEMIOLOGICAL ANALYSIS OF HIV AIDS IN THE CONTEXT OF NEPAL and we would like to express our gratefulness for entrusting us for this work. We would like to thank our seniors Miss. Sanju silwal and Miss Vinita Sharma for their guidance and instructions. We would also like to thank our respected teachers Mr.Subash Adhikari and Mr.Umesh Raj Aryal for their support. We would like to express our gratitude towards Mr.Shyam Shrestha and Dr. Shyam Lohani. We are indebted to all the teachers who helped us to prepare this term paper. We acknowledge the valuable support received from our friends. We will always be indebted to their important views and suggestions. This research paper would not have been successfully prepared without help of Nobel library which provided us with previous research paper and Annual reports. We in co-operation of computer lab of Nobel College and a number of individuals and organizations made our work easier. Group D BPH 2nd semester.

TABLE OF CONTENTS
1) Acknowledgement

ii iv v 1-5

2) List of figures 3) Abstract

4) Introduction

a) Background b) Statement of problem c) Purpose of study I) General Objectives II) Specific objectives Literature review e) Operational Definition 5) Methodology 6) Findings 7) Discussion 8) Conclusion 9) Recommendation 10) References 6 7-13 14-15 16 17 18

List of Tables and Figures:

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Page No. Table 1: Cumulative HIV infection by age-group Table 2: The cumulative HIV infection by sub-group and sex Table 3: Condition of HIV positive including (AIDS) and AIDS (Out of total HIV) Figure 1: Showing detection of HIV/AIDS by sex (1988-2005) Figure 2: Sex distribution of reported HIV positive cases in Nepal Figure 3: HIV prevalence in female Sex workers in Different areas Figure 4: HIV prevalence in High risk Groups in Terai Highway districts Figure 5: HIV prevalence in IDUs 7 8 10 9 10 11 12 13

Abstract
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This study was conducted to know the epidemiological status of HIV/AIDS in Nepal. This report reflects the HIV/AIDS status of different age group, sex, subgroup like IDUs, sex workers in different areas. . According to the Centers for Disease Control and Prevention, AIDS begins when a person with HIV infection has a CD4 cell count below 200 ("T-cells" or "helper cells of i"). However, because of the poor surveillance systems and the lack of access to quality voluntary counseling and testing services coupled with antiretroviral treatment these prevalence figures are likely to be a gross estimate. World Bank figures indicate that 1/3 of HIV infection nationwide is among drug users. HIV/AIDS is a global pandemic that has created challenges for physician, health infrastructures and government. Most cases of HIV infection in Nepal are HIV-1, although HIV-2 was recently reported. By using mathematical models it has been estimated that there were more than 70,256 people living with HIV/AIDS in Nepal at the end of 2005. HIV infection in Nepal mainly occurred among 15-49 years. If trends continue, AIDS will be the leading cause of death among 15-49 years old in the next ten years. AIDS is one of the deadliest communicable infections of twenty first century. Basically the study was launched to assess the trend of infection, identify the risk groups, availability of health services. The duration of study was from 10th June to 9th September 2009. It is cross-sectional analysis. It was prepared being based on secondary data. The situation in relation to HIV in Nepal is different from when the first case was diagnosed in 1988. Women are more vulnerable than men. Although women play role of sex workers or in mother - to- child transmission, most women acquire HIV from their sole regular partners and reducing acquisition of HIV among men is key to reducing the spread of HIV to women. . The sex worker population is also highly mobile and heterogeneous. Sex workers come from various backgrounds, though the majority hail from the lower socio-economic class, are married, and are between 15 and 28 years old. HIV/AIDS is no longer only a health issue; it is also a development issue. The school education curriculum should include a separate subject on safe sex, selfmanagement, sexual decision making skills,STDs,condom use, drug abuse, girl trafficking and HIV/AIDS incorporating some traditional ideas such as fatalism, sin of previous life etc.

Introduction a) Background

This term paper is prepared for the partial fulfillment of the requirements for the basic epidemiology, BPH 2nd semester. According to CDC, epidemiology is the study of the patterns of diseases and factors that cause disease in man. Human immunodeficiency virus (HIV) is a retro virus that can lead to Acquired Immune Deficiency syndrome (AIDS). HIV/AIDS is a major public health concern regarding the further growth potential of it within different regions. The HIV and aids epidemic continues to grow worldwide, present the global medical and public health communities with one of the most significant challenges. No other infection/disease has such an impact on humans than the degree of HIVAIDS does. Currently it accounts for the highest number of deaths by any single infectious agents. This pattern of devasting infection is caused by a virus, which attacks and destroys certain white blood cells that are essential to the bodys immune defense system. As the virus attacks and causes destruction and weakening of the bodys immune defense system its known as HIV. Aids represent the late clinical stage of infection. Worldwide, 40.3 million people are estimated to be living with HIV and aids. Among them, 18 million are women and 2.4 million are sufferers during 2006, an estimated 3.8 million are newly infected adults. About 95% of all infection occurs in low and middle income countries. HIV epidemics are largely concentrated among groups with high risk behaviors namely sex workers and their clients and IDUs. HIV/AIDS though harmful to human being, it is fully preventable too. Primarily it is sexually transmitted diseases and other way of transmission is regarded as secondary. Therefore, we can generalize that the span of HIV/AIDS is directly and entirely associated with the sexual behavior i.e. common, universal and natural behavior of human being. That is why it is essential to be alert from unprotected and unnatural sexual behavior to achieve that goal awareness is essential. In Nepalese context, the first case of aids was reported in Nepal in July 1988. Nepal is economically poor country having low literacy rate, less availability of health facilities and services and is open bordered with India which contributes to one of the largest group of HIV infected people globally. By March 2009, more than 2,258 cases of full blown AIDS and over 13,414 cases of HIV infection were reported officially.

According to the global AIDS epidemic report 2006, it is estimated around 75,000 people living with HIV/AIDS in Nepal. However, because of the poor surveillance systems and the lack of access to quality voluntary counseling and testing services coupled with antiretroviral treatment these prevalence figures are likely to be a gross estimate World Bank figures indicate that 1/3 of HIV infection nationwide is among drug users.

b)

Statement of problem

HIV/AIDS is a global pandemic that has created challenges for physician, health infrastructures and government. Most cases of HIV infection in Nepal are HIV-1, although HIV-2 was recently reported. By using mathematical models it has been estimated that there were more than 70,256 people living with HIV/AIDS in Nepal at the end of 2005. The largest number of reported HIV infection come from men who have been client of sex workers (49.6%) followed by IDU (20.9%).Female sex workers themselves form the largest group (8.5%). Recorded cases of blood and organ recipient are relatively low at around 0.2%. HIV infection in Nepal mainly occurred among 15-49 years. Most of the infected people are in the age group 20-39 years reflecting the highest reported number of HIV infection in the age group of 30-39 years. If trends continue, AIDS will be the leading cause of death among 15-49 years old in the next ten years. The extent of AIDS epidemic in Nepal will depend upon rates at which sexual partners are exchanged by commercial sex workers and the men who regularly visit them. There are extensive migration patterns both within the country and internationally, due to recent conflict, which provide the potential for considerable sexual networking. Man y factors drive the spread of the disease, such as poverty, homelessness, illiteracy, prostitution, women trafficking, stigma, discrimination and gender based inequality. These social, economic, legal and human rights factors affect not only the public health dimension of HIV/AIDS but also individuals physicians/health workers and patients, in context of Nepal fear of stigma and discrimination is a driving force behind the spread of HIV/AIDS. For the controlling of spread of HIV infection government must recognize, give special attention and acknowledge the needs of high risk groups i.e. drug users, commercial sex workers, and migrant workers. The 2002-2006 HIV/AIDS strategy proposed by government, which adopts a multisectoral approach focusing on prevention among vulnerable
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group, on control, care and support, and on voluntary counseling, and create target for achievement.

c) Purpose of Study
AIDS was first described in 1981. Since then, AIDS has become epidemic and pandemic as well. AIDS is a major global public health problem of this century and threat to human beings. AIDS is one of the deadliest communicable infections of twenty first century having no cure. Nepal is one of the countries having increasing burden of HIV infection that has lead to increasing number of AIDS cases. The study was made to identify the underlying caused and different factors that has aided in prevalence of the infection. Basically the study was launched to assess the trend of infection, identify the risk groups, availability of health services. The general and specific objectives of our research are as follows:

I) General Objectives
To assess the epidemiological analysis of HIVS/ AIDS in Nepal.

II) Specific Objectives

To assess the prevalence of HIV and AIDS in Nepal. To identify the risk group and vulnerable groups for HIV and AIDS. To assess the available services launched by government.
To assess the status of HIV/ AIDS in the context of Nepal.

To assess the relation of cross border issue in prevalence of HIV and AIDS.

d) Literature review
This chapter deals with general and specific literatures on HIV/AIDS. Sociologically HIV/AIDS epidemic is not only a health problem but also a social problem that has social and economic roots, consequences and solutions according to lyon, 1993. The onset of HIV/AIDS may bring a number of social, economic and psychological problems in the community and in the world as a whole. It could interfere the social life of a person infected by HIV/AIDS is an individual may tremendously affect the society and the nation as a whole according to Class, 1997. In some parts of Africa, HIV/AIDS is known as the family disease because it transfers from the parents to their siblings. The effect of HIV/AIDS operates at three different levels: the individual, the family and the wide society according to Redcross, 1990. Young people are the
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window of hope is changing the course of the HIV/AIDS pandemic preventing HIV infections among them is vital of the 40 million people living with HIV/AIDS according to cluster 2001. Lack of knowledge and access to contraceptive as well as vulnerability to sexual arouse put adolescents at high risk of unwanted pregnancy. Some of the surveys revealed that there is concentrated epidemic among injecting drug users and commercial sex workers according to WHO 2001. In traditional Nepali cultures and societies, any discussion on sex and sexuality is taboo. Husband and wife do not discuss sexuality and parents do not discuss sex with their children according to Upadhaya, 1995 Women are often forced into sex work through the need for money to maintain their families and children according to Karki et.al, 1999. Poverty, gender inequality, low levels of education and literacy, denial, stigma and discrimination are major contributing factors to HIV vulnerability in Nepal according to Nepal UNAIDS 2003. Male sexuality expresses itself in such behaviors as ingratiating with girls in a manner that carries social overtones, premarital sex multiple sexual relationships, extramarital sex and polygamy. Homosexual relationships are reported to be rare, particularly in the rural areas according to Mugrditchian et.al, 1998. Commercial sex is a cultural taboo and continues to be legal in Nepal. Among all factors in Nepal highest rate of HIV/AIDS is identified among the injecting drug users according to Jha, 1998... According to him, four main modes of HIV spread are namely sexual intercourse, infected blood and blood products, infected needle syringe, surgical instruments and infected pregnant women to her baby. In fact it is now apparent that Nepal has entered the stage of a concentrated epidemic, i.e. the HIV prevalence consistently exceeds 5 percent in one or more sub-groups. These include IDUS national wide, FSWS in urban areas, returning FSWS from India.

e) Operational Definitions
A. B. Prevalence of HIV and AIDS: The number of persons in a defined population who have a Trend of HIV and AIDS: It refers to the frequency distribution of disease according to the HIV/ AIDS at a point in time. Usually the time of a survey is done. age group population.
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C. D. E. F.

Risk and Vulnerability of HIV and AIDS: It denotes to the specific susceptibility of Stigma and Discrimination: Stigma is a social maker that labels people negatively as a Cross Border: It refers to across the Nepal-India border. Migration: It refers to relocation or movement of people from one place to another.

vulnerability of certain population sub-groups to the infection. deviant. Stigma may be about race physical disability sex and sexual orientation.

Methodology
Study Design: It is cross-sectional analysis. It was prepared being based on secondary

data.
Study Area: The study was conducted covering all areas of Nepal. Study Duration: The duration of study was from 10th June to 9th September 2009. 10

 Study population: population of Nepal Data Processing and Analysis: Data was processed and analyzed through Ms-Excel. Reliability and Validity: Data and information from reliable sources (published

document) were used. Limitation of Study: The study was only based on secondary data. The time limitation made it difficult to analyze other data so the report may cause biases.

Findings
Table 1: Cumulative HIV infection by age-group as on February 12, 2008

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Age group(years)

Male

Female

Total

New cases in March 2009

0-4 5-9 10-14 15-19 20-24 25-29 30-39 40-49 50 above Total

190 222 78 246 1169 2027 3630 1069 258 8889

114 156 55 253 795 1065 1540 434 113 4525

304 378 133 499 1964 3092 5170 1503 371 13414

2 7 4 1 14 28 49 35 11 151

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Source: Ministry of Health and Population, National Centre for AIDS and STD Control, Teku, Katmandu

It represents the Cumulative HIV infection by age-group which is expressed in numbers. The highest prevalence of HIV/AIDS can be seen in the age group 30-39 which mostly includes economically independent and covers 27% of total HIV infected cases followed by 25-29 and 2024.

Table 2: The cumulative HIV infection by sub-group and sex as on February 12, 2008 is tabulated below Sub groups Male Female Total New cases in March 2009 Sex Workers(SW) Clients of SWs/STD Housewives Blood or organ recipients Injecting Drug Users Men having sex with men(MSM) Children Sub-group NOT identified Total
479 53 8889 321 26 4525 800 79 13414 13 2 151 28 2367 (17.6%) 78 4 5880(43.8% ) 795 104 3221(24%) 11 47 799 5984 3221 39 2414** 78 4 48 61 1 18 4

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**Mode of Transmission- IDUs or Sexual Source: Ministry of Health and Population, National Centre for AIDS and STD Control, Teku, Katmandu as on March 13, 2009

It shows Cumulative HIV infection by sub-group and sex. The prevalence of HIV/AIDS is highest in the clients of sex workers which contributes 43.8% of total infection followed by housewives, injecting drug users which accounts for 24% and 17.6% respectively.

Figure 1: Showing detection of HIV/AIDS by sex (1988-2005)

Source: annual report, 2006

From the above chart, it is seen that the numbers of HIV infected had increased drastically in the year 1997 because of lack of adequate knowledge about HIV/AIDS and diagnostic methods; it has decreased after 1997 may be due to awareness about HIV/AIDS followed by increasing numbers up to 2004. The numbers increased as the numbers of sex workers and intravenous drug users increased. Again the numbers decreased in the year 2005 as there was behavioral change in the use of safety methods like condoms during sexual activities and exchange of needles and syringes among IDUs.
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Table 3: Condition of HIV positive including (AIDS) and AIDS (Out of total HIV)

Condition HIV positive including (AIDS) AIDS (out of total HIV)

Male
8889

Female
4525

New cases in this month

151

1601(16%)

657(13%)

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Source: Ministry of Health and Population, National Centre for AIDS and STD Control, Teku, Katmandu) as on March 13, 2009

Figure 2: Sex distribution of reported HIV positive cases in Nepal

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It shows condition of HIV in males and females as registered in Ministry of Health and Population who are HIV positive and turned into AIDS. 13% of HIV infected women have archived AIDS condition and 16% of HIV infected men have archived AIDS condition.

Figure 3: HIV prevalence in female Sex workers in Different areas

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HIV prevalence among Sex workers in Kathmandu and Terai highway districts decrease from 2% to around 1.5% in 2006

Figure 4: HIV prevalence in High risk Groups in Terai Highway districts

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Fig. 4. Shows that HIV prevalence is more among labour migrants than in other high risk groups in terai highway districts.

Figure 5: HIV prevalence in IDUs

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Figure 5 shows HIV prevalence among Intravenous drug users was 68% in kathmandu in 2002 and declined to 51.7%in 2005. Slightly decrease in Pokhara and EasternTerai in 2005compare to 2002.

Discussion
HIV transmission is very much related to sex. So the infection rate is very high in the reproductive age group (14-49 years) especially in the age group 30-39. This may be due to frequent exposure to
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infection through regular unprotected sex with sex workers with high prevalence of infection. They are the ones who migrate to cities or abroad, mostly to India to work. They are mostly single meaning either unmarried or living without their wives. Due to these they are more likely to indulge in premarital or extra marital sex which makes them prone to HIV/AIDS. Once they come back, they transmit it to their wives-the bridging population through whom transmits to their future baby. Shift in trend of age group with highest infection rate might have been due to increased migration rates. As in India, a major contributor to the spread of HIV in Nepal has been Nepals mobile population, including truckers and migrant workers. There are challenges to be addressed in the fight against HIV and AIDS. Nepal has a low prevalence for HIV and AIDS (0.5 percent). According to annual report 2006, some groups show evidence of a concentrated HIV epidemic e.g. sex workers 19.5 percent, migrant population 4-10 percent, and intravenous drug users (IVDU's), both in rural and urban areas, 68 percent. According to NCASC the prevalence of HIV/AIDS is highest in the clients of sex workers which contribute 43.8% of total infection. Different groups were first identified as vulnerable groups by NCASC. Later, other sub-groups were added as sub-populations at higher risk but again, new subgroups continue to emerge like blood and organ recipients and children. This change in risk and vulnerability might be due to the effect of the bridging population. The perfect example of this is the increasing incidence of HIV in housewives and the clients of the sex workers. These people are freely mobile in the population and increase the chance of transmission of the disease. The situation in relation to HIV in Nepal is different from when the first case was diagnosed in 1988. Women are more vulnerable than men. Although women play role of sex workers or in mother - to- child transmission, most women acquire HIV from their sole regular partners and reducing acquisition of HIV among men is key to reducing the spread of HIV to women. The alarming rise of the infection among women might also have been because the number of female sex workers is increasing. The sex worker population is also highly mobile and heterogeneous. Sex workers come from various backgrounds, though the majority hail from the lower socio-economic class, are married, and are between 15 and 28 years old. The vulnerable groups for HIV/AIDS recognized by NCASC are as followsa. Sex workers(SWs) and their clients b. Intravenous Drug users
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c. Mobile population d. Men having sex with men(MSM) e. Prisoners But now, the population at risk is even broader due to the effect of bridging population. The subpopulations at higher risk (PHR) include a. IDUs b. Sex-workers-street based and non street based c. Clients of sex-workers d. Labour migrants/transport workers e. MSM f. Partners of migrants/housewives g. Street children h. Uniform service

Conclusion
HIV/AIDS is no longer only a health issue; it is also a development issue. Tackling the epidemic will require not only prevention and control of HIV infection among vulnerable and risk groups, but a multi sectoral approach addressing the lack of access by risk groups to health care and education and recognition of the populations at risk People living with HIV and AIDS should be brought to the forefront in the fight against HIV/AIDS. Family members, community,
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organizations, donors, and the government all have their own important role to play. As with all international declarations on HIV/AIDS; there is need to take a strong human rights approach to combating the epidemic. This includes recognizing fundamental rights such as access to health care and information, addressing gender equity, and effort to reduce sex trafficking. It further requires addressing the root causes of poverty and inequality, which give rise to migration and Trafficking as well as propagate violent uprisings. In the year 2008, 69% male and 31% female were infected with HIV. In the year 2009, 66% male and 34% female were infected with HIV/AIDS. There was increase in total number of HIV/AIDS infected people. But there is also variation in the percentage of infection of male and female. The percentage of infection of male has decreased by 3% and the percentage of female has increased. If we compare the data between 2008 and 2009 published by NCASC, the infection of HIV in age group 0-4 by 0.3%;0.3% in 5-9; 0.2% in 10-14; 0.2% in 30-39; 0.9% in 40-49; and decreased by 0.5% in 15-19; 1.1% in 20-24; 0.8% in 25-29 years. Similarly, when the study of HIV infection was made on the basis of sub-group and sex on 2008 and 2009. Infection increased in housewives by 3%;0.1% in blood or organ recipient; 0.2% in MSM; 0.8% in children; and decreased by 0.7 in SWs; 1.4 % in the clients;1.7% IDUs; while there is no change in % in sub-group NOT identified.

Recommendations
The school education curriculum should include a separate subject on safe sex, self-management, sexual decision making skills,STDs,condom use, drug abuse, girl trafficking and HIV/AIDS incorporating some traditional ideas such as fatalism, sin of previous life etc. Poverty, illiteracy, migration, gender inequality, shifts in trend and cross border issues are the major factors contributing for the prevalence of HIV/AIDS in Nepal. Poverty, illiteracy, and migration are interlinked. If poverty can be eliminated, illiteracy and migration might be reduced. So the concerned authority should be devoted to reduce poverty.
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Gender inequality may act as a major cause of improper health seeking behavior. Stigma and discrimination, related closely, also affect the recording and reporting system. Education and literacy rate determines the formation, structure and utilization of legal framework. Moreover, all above the mentioned factors share some relationship with one another and determine the accessibility to health services, which in turn affects transmission, prevention and prevalence of HIV and AIDS in Nepal. Shift in trend of age group with highest infection rate might have been due to increased migration rates, which again relates to poverty in the country. This shift has also dramatically increased the area of risk and vulnerability. Inclusion of partners of migrants and housewives, uniform service and street children under sub population at higher risk by NCASC indicates how the concentrated epidemic is slowly taking a generalized form. The presence of bridging population is also playing a vital role in bringing about these changes. Cross border issue is not just a political issue anymore. Its impact in increasing HIV cases in Nepal has shown how open border between Nepal and India shapes of the epidemiology of the disease in the country. Establishing more Anti-retroviral therapy (ART) sites can no longer control spread of HIV and AIDS. Very less number of studies and researches has been performed to study the prevalence of HIV/AIDS in Nepal. Dissemination of knowledge relating to HIV prevalence in Nepal is not coordinate. There is no central point of reference for such materials. Given the number of agencies involved, formal coordination and dissemination of information is required.

References
1. National Centre for AIDS and STD Control (NCASC) 2. HIV & AIDS IN THE SAARC REGION by SAARC Tuberculosis center(STAC), Thimi, Bhaktapur, Nepal (Page no;51-59) 3. Term paper on Social Epidemiology of HIV/AIDS (2006) in Nepal, Nobel Library Katmandu 4. Department of Health Services (Annual report 2006)
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and HIV/AIDS

5. Gupta and Gupta, Rohans New Illustrated Medical Dictionary, A.I.T.B.S publishers and

Distributors, Krishna Nagar, Delhi, 2006.

6. Website:- Google search on status of HIV /AIDS in Nepal

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