. A middle-age woman in Bayalpata lies in bed covered with a blanket, shivering. Her husband returned from India two years ago and died. She too fell ill and was diagnosed HIV-positive, she didn't try to hide her infection and was ostracised. While she still could she tried to spread awareness among other women in her village about AIDS but now she is too weak.

. The 29-year-old man had returned from India four years ago. He had been ill and the villagers all thought he had tuberculosis. Last month, he died of AIDS. "We hadn't told anyone he had AIDS because it would have been difficult to live here," admits his brother.

. In Muli, two young men who had recently returned from India fell sick. They were being treated in the district hospital but were not responding to the antibiotics. The doctors finally got a blood test done and found they were both HIV-positive. Both are now dead.

Mid-western Nepal's Achham district has traditionally been an area of heavy out-migration of seasonal workers to India. Even during peace, up to 40 percent of Achham's population would be in India at any given time.

Today, with the insurgency, the district administration estimates that 60 percent of Achham's population is away. The result is starkly visible: there are few able-bodied men left in Achham's 75 VDCs.

Most of the men have traditionally gone to Mumbai to work as chowkidars, and stay away for three to four years before returning. In Mumbai, many visit brothels to spend time with young women from Nepal for comfort and sex. There are an estimated 100,000 Nepali women sex workers in Mumbai alone and many are HIV-positive.

One returnee told us that Nepali men get discounts for sex, and some even have 'season tickets' and keep their favourite girls and young women on a monthly retainer. When they fall sick and can't work, the men come home and infect their wives. The assistant health worker at Achham's district hospital in Mangalsen, Jhapat Rawal, says HIV entered Achham through workers returning from India. "Most of those infected have recently returned from India or have come in contact with them," he says. But anti-AIDS activists here say blaming those returning from India for the epidemic may have been true in the past but now the virus is spreading rapidly within Achham and Nepal.

The conflict in Nepal's midwest has escalated outmigration from Achham and surrounding districts, thereby increasing the danger of infection. Officials at the District Health Office in Mangalsen admit that there is no way of telling how bad the situation is because they can't go to the villages to conduct surveys. "The situation must have grown worse but we just don't know how much" says Khadga Bista of the district AIDS coordination committee. A recent survey carried out by two non-governmental groups in 12 VDCs showed that there had been 128 deaths due to AIDS so far with 85 new infections and 250 AIDS orphans. "We went house to house, asking how they died, how many children they had and who else was sick, but we don't know what the situation is like in the rest of the 75 districts," says Yogendra Oli of Gangotri Gramin Bikas Manch.

According to the last census, Achham's population was 231,000, but nearly half of them could be working in India or have become internally displaced by now. If Gangotri's survey is extrapolated to all the districts, some 1,500 people may have already died of AIDS here. There is no estimate about HIV infections. Their situation could be serious because the public health system in the mid-west has collapsed because of the conflict. Once infected, HIV patients have no access to health care.

The German aid group, GTZ recently gave 100 HIV detection kits to the hospital in Mangalsen but it is clear the AIDS clinic will soon run out of kits. In one week this April, of the 10 persons tested, five turned out to be HIV-positive, and two have since died. All five had returned from India. Jhapat Rawal recalls: "We first treated them thinking it was TB, but they didn't get better so we tested them."

As it is, Achham already had one of the lowest nutrition levels and alarming anemia especially among young girls and women. The social standing of women in Achham society is poor and food intake has dropped because of conflict-related disruptions. All this adds up to a lowering of resistance so that after women are infected, death comes quickly. Even those with opportunistic tuberculosis or other infections don't get medicines because health posts have closed down and medicines are not sent out to the villages for fear it will get into Maoist hands.

Jiraj Shakya is a doctor at the Bheri Zonal Hospital in Nepalganj, he says the AIDS crisis in mid-western Nepal is reaching serious proportions because the virus keeps coming into the country through workers returning from India and warns that the response so far has been inadequate. "We must tackle the problem at its root, through local awareness and by targeting returnees. It is already getting too late," Shakya says.