Breaking The Silence On HIV In Nepal

By Sudeshna Sarkar, Womens Feature Service

In Kathmandu, the star-petalled poinsettias are in bloom in every garden with their message of hope. But hope is precisely what many young people caught in the dark alleys of drug abuse in Kathmandu or Pokhara do not have. Nobody knows this better than Bishal Manandhar, an events manager with the Kathmandu-based organisation, Faith, and a former Injecting Drug User (IDU) himself.

Now in his thirties, Manandhar was just a boy when he was first introduced to the drug scene. He recalls, “As a student in a school in India, I was shy, kind of quiet, and kept largely to myself. In Class 9, I became a part of a group of local boys who were discovering ways to get a high. We used cough syrups like Phensidryl, and marijuana.” Back in Nepal after school, he felt the need to continue taking drugs to boost his low sense of self-esteem. “The government then banned Phensidryl, so we started looking for ways to get a high in a cost effective way. That was when we started injecting ourselves. In between, I also took brown sugar. I was soon addicted and remained so for the next 11 to 12 years. In other words, I did drugs in some form or other for almost 19 years,” says Manandhar.

What many like him did not know was that as IDUs, they were also in danger of contracting HIV/AIDS through infected syringes. Manandhar’s voice is flat and gruff when he remarks, “I have been exposed to so many tragedies. So many of my friends have died, and I realised that they died because they kept their condition to themselves. For instance, they did not know the links between HIV and TB. A very close friend of mine died at the age of 25 of this. He knew he was infected but told nobody about it.”

Manandhar’s trajectory is fairly typical of many others who are caught in the descending spiral of drug addiction. Kicking the habit for him was not an easy process. As he puts it, “I went through several rehabilitation and detox programmes; through several cycles of recovery and relapse. Wanted desperately to quit and looked enviously at some who had. They became my mentors and helped me. But finally it was a ‘didi’ (elder sister) from the organisation Life-saving and Life-giving Society (LALS) who helped me. She even got me to help her set up an organisation, Prena, run by HIV-positives for HIV-positives.”

Today, it is he who is playing didi’s role of guiding young addicts out of their private hell. He does this in innumerable and creative ways through songs, videos and art competitions for kids. He continues to be associated with LALS, which has been running a nearly-two-decade-old harm reduction programme of distributing sterile syringes in exchange for contaminated ones. To reach out to a group that prefers to lead twilight lives, Manandhar also helps stage public cricket matches in which HIV-positive kids participate, along with bankers, corporate managers and college teachers. “The idea is to break the silence, reach out to these kids, encourage them to see things differently, and break out of the prison of drug use,” he says.

The 2009 IBBS infection estimation indicates that the HIV prevalence among male IDUs was 20.7 per cent showing a significant decline from the previous years. Notes Dr Krishna Kumar Rai, Director, National Centre for AIDS and STD Control, Nepal, “The HIV programme in Nepal had made very good progress precisely because it has focused on the most-at-risk population: Commercial sex workers, men having sex with men, migrant labourers and intravenous drug users. We work with civil society groups providing comprehensive care packages for them, including awareness programmes and needle exchange programmes.”

But he also underlines the need to reach out to the low-risk categories: “The number of people with HIV/AIDS in Nepal was estimated to be around 64,000 in 2009. The incidence was 0.49 per cent in 2002-03, but efforts helped to bring this level down to 0.39 per cent. However, this is for the most-at-risk population. Cases are rising in the general population with about 13 new infections being reported every day – many in this category are wives of migrant workers.” Dr Rai estimates that there are about three million migrant workers from Nepal in India alone. They contract the disease and their wives get infected. The Nepal government is now trying to develop a comprehensive service package for migrants at the place of origin as well as transit so that they are better educated about the risks and about condom use.

Dr Rai believes that the Nepal HIV/AIDS control programme has benefited greatly from its technical partnership with the World Health Organization (WHO). Dr Min Thwe, WHO’s Medical Officer for HIV/AIDS, explains how the partnership works, “WHO tries to make sure that the activities and strategies to address HIV/AIDS in Nepal are in line with global, regional and country level best practices. It also ensures up-to-date health technologies to address this concern.”

Global Fund has also played a significant role by providing financial support. In 2003-04, it sponsored antiretroviral therapy kits. In 2007, it provided Nepal with $35 million for its national HIV/AIDS programme. According to Dr Rai, Nepal could not have fought HIV/AIDS on its own, “In 2004, Nepal started ART services with just one centre. Today, there are 35 centres and it is being provided to PLHA coming mostly from the most-at-risk population, free of cost. It was support from the Global Fund that made all this possible. It would have been disaster if Nepal lacked the financial resources to fight HIV/AIDS.”

There is evidence that the Nepal government is going to address the social issues and problem of stigma and discrimination through social advocacy, information and education and also through legal measures for which the ministry of health and population has started the process of developing a law to penalise any discrimination against those living with HIV/AIDS. A fund for the widows of people who have died of HIV/AIDS and for orphan children are under consideration. Dr Rai has publicly voiced his misgivings about any approach that criminalises sex workers, “I have always believed that if sex workers are punished, they will hide their identity and will be discouraged from using preventive measures. Sex workers and their clients bridge the infection from the most-at-risk population to the general public. Some of them may not be aware that they are infected. Police action against them can actually promote transmission of HIV/AIDS rather than prevent it.”

For women like Bina, 45, a former sex worker, who is presently working as a counsellor for a local organisation in Kathmandu, this is the way to go. “Through all my years in the business, I never knew about a disease like HIV/AIDS. Today, my primary job as a community mobiliser is to use my own experiences to counsel other women in prostitution and tell them of the dangers they face. In some way or other, all our stories are alike. We are all children who were abandoned or who fell by the wayside. We need information and assistance, not police action.”

According to Dr Min Thwe, the strength of the HIV/AIDS programme in Nepal comes from the public articulation of the issue. “In Nepal today, HIV/AIDS is recognised as a problem and there is an active partnership of the health authorities with Civil Society Organisations, particularly for interventions among the most-at-risk population. This is what makes for its success,” he says.

A new generation in Nepal is now vulnerable to a disease that first surfaced in the country in 1988. As Manandhar observes, “Time has gone by but the problem has not gone away. Now even students in Class Eight are given pocket money and their own scooters by indulgent parents. They hang out with older kids and get sucked into the world of experimenting with drugs and risky behaviour. We cannot afford to shut them away. We need to engage with them, talk their language. That’s why I sing songs to get my messages across to them. One of the lyrics of a song I sing goes like this – ‘In my loneliness/In my darkness, be the light/ Show me the way’ – I really feel we have to show them the way.”

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