Nepali Times
Into the valley of AIDS

There was a time when HIV-AIDS was regarded as a donor preoccupation. It was considered the prerogative of perverts and outsiders. Most of us blamed Nepali girls in Bombay or drug addicts, and considered ourselves risk-free. No more.

Today, alarm bells are ringing loudly. Public health experts are shocked by the frightening speed at which the disease is spreading in Nepal, and especially in Kathmandu Valley. They are also dismayed at the lack of political will and the prevailing official confusion over preventive measures.

There is growing recognition of the serious economic consequences of an Africa-type nationwide epidemic but Nepali officialdom is still largely in denial.

\'We are sitting on top of a volcano," says Michael Hahn, of the UNAIDS office in Kathmandu. "Nepal has entered a concentrated epidemic, and there is a window of opportunity to prevent a generalised epidemic if steps are taken immediately."

The latest Family Health International survey shows the following figures:

? 17.3% of sex workers in Kathmandu are HIV positive, up from 2.7% four years ago
? Half of all injecting drug users in Kathmandu Valley are infected
? More than 80% of injecting drug users are sexually active, and 40% are married
? Nepal\'s nationwide estimates for HIV/AIDS cases is now crossing 35,000.

HIV. the virus that causes AIDS, is spread mainly by unprotected sex and direct blood contact like sharing injection needles or blood transfusions.

A survey of 19 urban areasin Nepal showed very high infection rates for HIV. hepatitis C and B and other sexually transmitted infections among injecting drug users. (See graph below.) "The findings suggest there is a potential for rapid spread of HIV and there is a need for urgent prevention and care. If it is not taken, the infection can spread to the general population." says Dr B B Karki, chief of Policy Planning at the Ministry of Health.

The risk for drug users, and the section of the population that visits sex workers or has multiple sex partners, needs to be reduced.

Reducing vulnerability means ensuring not only that brothel clients and intra-venous (IV) drug users know about the dangers of infection, but that they also take preventive measures.

It also means giving the drug users alternatives like safe needles and less harmful drugs while they work towards kicking the habit-a process known as "harm reduction".

"The most effective way to stop the spread of HIV and hepatitis among injecting drug users is ensuring that needles are not shared," says Sambhu Dhital, a community health worker at the Live Giving and Life Saving (LALS) organisation in Kathmandu.

LALS has been working on harm reduction with counselling, family meetings, rehabilitation, and needle exchange programmes for drug users in Kathmandu. But LALS reaches less than five percent of the estimated 30,000 injecting drug users in Kathmandu.

Most IV drug users in Kathmandu don\'t use hard drugs like heroin, but cheaper "pharmaceutical drugs" like tidigesic, a sedative containing morphine, synthetic morphine, codeine, or benzodizapom. LALS estimates that drug users in Kathmandu spend an Rs 5 million a day.

Figures for the number of sex workers in Kathmandu Valley vary wildly: from 5,000-25,000. One survey in 1996 showed that 15 percent of them never used condoms. 21 percent did. and 56 percent "sometimes did and sometimes didn\'t".

Even if sex workers had heard about AIDS and condoms, and knew how to protect themselves, they were often forced by clients who didn\'t want to use condoms. An average Kathmandu sex worker services three clients a day-making the 30,000 men who liaise with them every day the key vectors of this epidemic. Many clients are themselves male migrant workers who have returned from India with HIV.

Most clients are married, or have other partners, and the chances of infections spreading into the general population are very high. This is why public health experts warn: everyone is now at risk.

With half the injecting drug users HIV positive, this group is another important target group if the epidemic is to be controlled.

We know what does not work: the police approach. Cracking down on IV drug users, putting them in jail hasn\'t worked anywhere in the world. It just criminalises drug use and drives addicts underground.

One place in the region with a similar problem to Kathmandu Valley is the eastern Indian state of Manipur, bordering Burma. Up to 70 percent of injecting drug users in Manipur are HIV positive.

At a recent AIDS conference, Manipur\'s minister of health, Morung Makunga sounded a warning for Nepal: "I appeal to you, don\'t make the mistake we made of arresting drug addicts and punishing them to control HIV/AIDS. In countries like Nepal, the epidemic among injecting drug users is just taking off, you have plenty of opportunities to think of new strategies."

It was only after Manipur became the only state in India to adopt the three-pronged approach of counselling, drug maintenance therapy and needle exchange that the epidemic there started showing signs of slowing.

And this could only happen because of political will at the highest level, and a coordinated approach among government departments, the police and activists.

Health experts say a similar "Harm Reduction" strategy is required for Kathmandu Valley that will go step by step to:

? Persuade drug users to stop injecting
? Get injecting drug users to switch to other less harmful drugs
? Persuade them to stop sharing needles if they can\'t stop injecting
? Get them to clean needles if they have to share
? Stop using drugs

Vijay Kumar is an Indian activist from Manipur who is now with Save the Children (UK) in Kathmandu. He says, "The biggest problem in Nepal is that at the government level there is a clash between those who favour harm reduction, and those who want to use the police model," he says.

Unfortunately, drug users are often seen as deviants, law enforcers are known to get a cut from street transactions, and there is low tolerance for needle exchange because of the public perception that it encourages addicts.

Kumar\'s other experience from Manipur is the serious implication of the epidemic on women and children as the men start dying at a productive age. "We have seen what a crisis this can be for widows and orphans, many of whom are also infected, and are then stigmatised by society and have no support."

There is no doubt that to come to grips with the epidemic the government and activists must urgently reach a critical mass of sex workers, their clients and injecting drug users.

Hahn of UNAIDS says a piecemeal approach will have no impact: "We have to get to at least 80 percent of those who need access to protection if we are going to make a dent on this epidemic."

In the end it boils down to resources. In India, the unit cost of getting an injecting drug user rehabilitated is $30 per person per year. With 30.000 drug users, less than a million dollars would be enough for Kathmandu Valley.

The cost of doing nothing would run into hundreds of millions in the years ahead for the Nepali economy.

(11 JAN 2013 - 17 JAN 2013)