Tuesday, March 23, 2010

Street Drama: Powerful Tool to Raise Awareness


Photo is taken on April 2008 in Kolti of Bajura District (Farwestern Nepal). The street drama was led by local youth club and was related to Uterine prolapse and HIV awareness.

Script was provided by professionals and local words were used in Nepali scripts so that it would reach more people. Same program was repeated in two more districts

Bajura District: This district is not linked to road services todate. Plane is irregular from Nepalgunj. Usually flies once a week to Kolti( eastern area of Bajura). From Kotli, one has to walk full day to reach district headquarter. To reach vehicles, One day walk (more tan 10hrs) is necessary to get bus from Budhbagar of Achham District.

Radio Listeners' Group


Radio Group:

Radio is the major source of information in Nepal specially in hilly and himalayan region.

The photo is taken while a radio listerners' group was listening HIV/AIDS message in western Nepal.

Female Community Health Volunteers' Meeting


Community Based Programs are the leading programs which are contributing to reduction in mortality and morbidity.

Female Community Health Volunteers are the backbone of each community based progra.

This photo taken in March.2008 in Eastern Belt of Jumla District(Karnali region) while local health staffs were discussing HIV AIDS and RH issue for planned RH mobile camp.

Jumla is situated in Karnali region. It has a seasonal road linkage with Nepalgunj and regular plan facility. Within Jumla, some seasonal roads are under construction.

Saturday, March 20, 2010

Female Sex Workers: A MARP for HIV in Nepal

Sex trade exchanged in favour of kind and cash has been long practice in all socieity. In Nepal, the system has been seen and hidden since the long time ago.The majority of sex trade are carried out in market places. Namely the places are Kathmandu, Pokhara, Dharan, Biratnagar, Narayangadh, and major cities. Again, highway suburds are the major vulnerable places. Current development paradigm has made the rural people to have more access to roads and rapid movement of the populatons. This change in mobility ofthe population has led to an exposure to previosly unseen markets of sex trade in Nepal as well.

Legal Status of Sex Trade in Nepal:
Sex trade is illegal in Nepal.

Estimated Female Sex Workers in Nepal:

World Bank's estimates says there are 25,00-34,000 active commercial sex workes in Nepal. Besides Nepal, estimated 200,000 women are sold in Indian market of Nepal for sex trade the literatures suggest. Number of forced sex workers who are from Nepal and are serving in Circus of India are unpredicted.
Of all the sex workers; 15017% are street based. Five per sex workers are from outside of Nepal.



Profile of Female Sex Workers:

Kathmandu based sex workers' finding shows that 39% are street based, 32% are illeterate, 29% are single(divorced or separated). One third are less than 20 years of age. 60% had first sexual contact while they were of age 15-19 years showing the early initiation of sexual contact.( FHI IBBS,2006)
Another finding from highway district of Nepal reveals two third were illeterate, and one fith were less than 20 years of age. One fourth were single(divorced or separated. Median age of FSWs was 27 yrs. ( FHI, IBBS,2006)
World Bank estimates about half of the FSWs are returnees from trafficking from India(World Bank,2004).

Knowledge and Practice regarding HIV and AIDS:

Outside valley reseach shows 68% know sexual contact transmit HIV. However 98 % heard of HIV. 60% knew about the A.B and C method of HIV prevention. Kathmandu based research shows 99.4% FSW s heard of HIV and only 30.2% have heard of A,B,and C method of HIV prevention.(lower than others) (FHI,2006).

What ever the knowledge level is , only 11% of Capital based and 43% of out of Capital based FSWs use condom regularly. 1.5 is the average client per day for Kathmandu (the capital city) and 1.0 is for out of capital FSWs.

HIV prevelence in FSW is 1.5% which is similar in both studies.

More than 95% of FSWs were suffering from STIs but less than 5% has reached health facilities for treatment of the symptoms. Since STI presence significantly increases the risk of HIV transmission, this points suggests the gap to be filled immediately.


Access to Health Care:

The less than 5% FSWs who search for care of SITS has given private clinic, NGO run clinic and pharmacies as their preference over public facilities. Lack of confidenitialy, Discrimination by government health workers, negative attitud of service providers, poor communication and fear of being exposed were the some of the hinderances that makes FSW not to prefer government health facilities even if GON facilities are technically sound and well equipped. ( GHIMIRE Laxmi, 2009)
Right based approach to health service centre is not well established in Nepal. All the White coat holders(Health Workers) treat patients and clients as if they are giving them mercy or so. So, this is what the major policy lag in health system of Nepal which is making this risk goup out of reach groups to deprived of proper health care.



Changing Markets:
Soft prostitution, male prostitutes available for women, and international link of prostitutions in Nepal are some of the emerging issue in FSWs of Nepal. The current unofficial reports says that openness in sexual habits and rampant mobility has made more vulnerable groups. Some ameture sex workers are also in the markets. Some evidence has shown that someof the college students are involved in soft prostitution as well.



Deuki and Badi: Social Prostitution:

BADI system:
The badi were originally an entertainment caste - singers, dancers and musicians. Men of the community also fished and manufactured madal drums and fishing nets. Political, cultural and economic changes, particularly over the last fifty years, have contributed to and produced the development and practice of prostitution as a strategy of survival for many in the Badi community. Subsequently, it has been said that prostitution is the "traditional caste occupation" of the Badi and it has often been defined thus as a part of the caste system. In line with the socio-political transformations taking place in Nepal from the early 1950s and with the growth of prostitution, many male family members became economically dependent on the earnings of women. That situation was partially responsible for the loss of traditional community skills and professions.
As this sytem arised out of the social system,some of the Badi women show their anger like this'" "I eloped with a man from the low caste as my parents did not approve my marriage with him. We moved to Kathmandu and settled here. He was a micro-bus driver (one of the means of local transport), and I gave birth to two children, a son and a daughter. But as year passed by he stopped coming to home and when he did he used to become violent and beat me and my children and did not provide any monetary support. With no skills and education I had to make my children sleep with empty stomach and withdraw them from their school. And one day I discovered that he has been staying with the girl of his own caste in another part of the city. After that followed the arguments, verbal and sexual abuse and he finally moved to stay with that woman. I left my family for him and was so devastated and wanted to commit suicide but due to my responsibility to look after my children I could not do that also. Then with the hope to get into foreign employment I borrowed the amount of Nrs 35,000 and paid to the broker but during my health check-up, HIV virus was seen in my blood. So with no skills and nowhere to go I ended up as a commercial sex worker knowing I am infected with the virus. As he ruined me I want to ruin the men of this society by transmitting the virus"
This was the story told by one of the woman at Raksha Nepal and the essence of this statement might not be confined to one particular commercial sex worker but to many as women are into these situations as men they trusted and believed let them wander in the streets. Imagine yourself being born to the Badi community of Far western region of Nepal who has been given the tag of commercial sex worker right after the birth or yourself being offered to the temple as one of the offerings or imagine yourself being sold to the brothels or using commercial sex work as a last resort to sustain your life. How difficult is to imagine but the thousands of women in Nepal are going through this fate and are vulnerable to acquire and transmit HIV/AIDS. ( For readers' knowledge I have quoted this story from a case study by Ms. Anjana at http://www.worldpulse.com/node/12108).
However formally, this Badi system is abolished from Nepal. Many Badi women are taking lead to change their society to take out of this curse. State has made this act illegal now. Hence, the scenario will not be found in near future.


DUEKI Sytem of Nepal:

In 2007 according to a UN report, there werel nearly 30,000 deukis in Nepal compared to 1992, when there were 17,000 deuki girls according to the UN Special Report on Violence against Women.


Deuki is an age old vicious custom still practiced in many districts of Sethi and Mahakali zones in the far western region of Nepal. Deuki means to consecrate one's own or a poor family's newly born female child to god in order to fulfill a promise made earlier to gain religious merit.

Based on blind belief, the practice of deuki is to offer an innocent female child to the local temple to serve the god or goddess in order to gain a son, to cure a sickness, or to fulfill any other desires.

The center of this practice is located in Baitadi district's Melauli Devi temple. According to locals, around 2,000 such deukis exist in the various temples.Bought from poor families for Rs10,000 (U.S.$140) to Rs100,000 ($1400), no one takes on the responsibility to care for these children offered to the temples.
With virtually no one to take care of them, the children have to depend on and live off the offerings made to the temples. But because of the poor state of the nation and the frugal income generated by the area's temples, they are forced to find alternative ways to survive. As a result, they often end up selling their bodies.
The flesh trade of the deukis is on the rise. Misguided by their own selfishness, prominent locals spread the blind belief that sex with a deuki will give them religious merit. Is some cases, it has been reported that the families of those who sell such deukis to the temples have sexually exploited them.
Girls born from such copulations themselves are sold into deukis, while sons become religious healers. Meanwhile, people have started speaking out against the deuki custom. Many women's activist and human rights activists have called the deuki custom a transgression of human rights. But regrettably, the government has not taken any steps to put an end to this sick and depressing custom. Rather, it remains, staining the whole of Nepalese civilization with the tears of those unfortunate girls we call deukis.


Recommendations by Different Studies Regarding FSWs:

Some of the research findings have summarized the following recommendations to reduce HIV transmission among FSWs;
- Government should take ethical responsibility
-Free condom distribution should be made more intensive through more outlets
-Massive awareness and BCC intervention to transform safe habit
-Peer educator, outreach services and mobile clinics
-Expansion of functional VCTs
- Institutionalization of Right Based Approach to Health Care Delivery System.

Journey of Madhumaya from a Women to a Social Worker


Journey Of Madhumaya From a Woman To a Social Worker

March 17, 2010. Madhumaya was working in her house while we visited her. She has been working as a FCHV for more than one decade in ward No. 1 of Thaprek VDC of Tanahun district. She had got her schooling to class 8only and got married. Now, she has her two daughters and one son who are pursuing their higher studies in Damauli and Kathmandu. Thaprek Health Post In Charge Mr. Raghu Nath Bhattarai says, “ Madhumaya is the most dedicated FCHV of my VDC and she has been leading other FCHVs for taking initiatives in health programs of VDCs”. While discussion her journey as a FCHV she states,
“I am working as a FCHV for this ward for eleven years. I am providing services for mother and children including first aid for all. I also treat pneumonia of children who are less than five years of age.
Initially, as a FCHV, I used to provide first aid, distribute ORS and provide health education to the people of my ward. After getting training on CB-IMCI, I got to learn how to identify the pneumonia with help of timer. Now, I can use timer, classification card, cotrim treatment card and medicine for treating pneumonia. It has been almost four years that I am treating pneumonia in my own place. To date more than hundred cases got treatment from me. Yes, some child didn’t get well; I sent them to hospital as I learned to do so in my training. So, people now bring their children to get suggestion for treatment as well receive treatment while children are sick.
Not only as a FCHV but also as a trained traditional birth attendant, I am confident in providing advices to the mothers in my community. Immediately after my training as a trained traditional birth attendant, I have saved life of a woman who was unable to expel placenta. As she had no body to bring her to me, I went to her house. I examined her and found she was bleeding and also had her full bladder. I suggested her to micturate so that her bladder would be empty. I also suggested the family member to give her hot fluids. I also made her to breast feed her baby. Within few minutes, she expelled placenta and her bleeding also stopped. Since then, I am treating and suggesting for illness of herself and her children.
Now one decade has gone and my service is continued. I was unknown as an individual in my place. Now, ask anybody in the village, they know me, and the most important, they believe me. They come to me and look for my advice. In the recent campaign of filariasis program, everybody got medicine from me and hence, my village and ward knows me for what I work for. You would never have come to me if I were not a FCHV. Previously, I used to have shaking my feet and lose my words when I spoke to public and unknown people and I could not express myself. Now I can express what I feel, what I know and what I need. Now health facilities, local community organizations, VDC and local school call me for my service, suggestion and participation. My voice is heard in every institution in my place. I am also involved in all social works, school management committee, and community organization and consumer group of our village. Just in one line I can say previously I used to search others but now society and organizations search me. These things make me feel self esteemed and I find myself a valuable member of my society.
I recall the days while I was not a FCHV. I used to stay in my home. I was recognized as a member of my family only and not as a single individual. Now, people know me by my name as a FCHV. My husband and family member also had supported me for all these endeavors. My husband supports me for household work while I am busy in mother’s group meeting, immunization clinic and other social groups. Family members now make time for allowing me for my social involvement as a part of routine work and hence I feel, days are easier than before. While I am discussing with you about the matter, look my husband is working in household. While I am showing some children of my village he will be preparing meal for us. Do you accept to have meal with us?
Being a FCHV, I am trained in CB-IMCI and TTBA from DACAW program of UNICEF as our health post in charge informed me. TTBA training was conducted in district head quarter where I got to learn a lot on care of pregnancy, child bearing and post partum. Before CB-IMCI training, I used to provide home therapy advice, first-aid and referral. After CB-IMCI training, I am treating the cases in my village. As our health post staffs shared our review meetings are also supported by UNICEF. You know, this type of review meetings are very important for us as we get new energy to work. Thanks UNICEF! For helping us saving lives of our children and mothers. We know new things to learn from health post staffs and other FCHVs. Community mobilizer in our village conducts regular growth monitoring program for our children. I also got support from village facilitator. I am also supporting local child development centre for childhood illness management”.
“We have a child development centre in our village. There are 26 children of our village. One facilitator help these children. We have good relation with our FHCV to support each other. If our facilitator finds any illness in children she sends the child to Madhumaya (the FCHV). Madhumaya first examine the child and either provide medicine or suggestions. Again, based on Madhumaya’s suggestion, our facilitator makes follow up. Since our children get treatment from FCVH, it has been good support for our child development centre”, says Mr. Lekhnath Panthee, the president of a local child development centre. He adds, “ Since we get help from her, we also help her for immunization days, polio and vit.A day and, as she requests”.
“ She saved my daughter in law while my daughter in law was not able to expel placenta and bleeding” says Ms. Bal Kumari Mishra a 66-year old Mother-in-law of the women that FCHV stated above. She adds “I have two grand children. Both of them become sick time and again. We always take them to Madhumaya (FCHV) to get treatment. She has a machine that says if our child has pneumonia. If our child has pneumonia, she gives medicine for free.” If we stop FCHVs to provide service in the community? A question that makes her feel unpleasant. She replies, “Why should government stop her service? She is providing service for our children, women and all. Even if government stops her service, I know she will help us by providing suggestions while we and our children are sick”. If mothers’ group meeting propose you to be FCHV for this ward, will you accept the post? The question that makes her face blushed for a while. She say, “ Ha ha! I think I am too old to take all the responsibilities of FCHVs. Yes, if I were of your age, I would happily accept to be a FCHV”.

HIV and AIDS in Nepal: A brief note


HIV and AIDS in Nepal

Background:
Since the detection of the first AIDS case in 1988, the HIV epidemic in Nepal has evolved from a low prevalence to concentrated epidemic. As of 2007, national estimates indicate that approximately 70,000 adults and children are infected with the HIV virus in Nepal, with an estimated prevalence of about 0.49% in the adult population. As of Ashadh 2064, a total of 9756 cases of HIV, 1454 AIDS cases and 423 AIDS deaths had been reported to the National Centre for AIDS and STD control (NCASC). The sex ratio among HIV positive cases is 2:1.
Nepal is categorized as a “Concentrated” epidemic country as some of the sub population groups (IDUs, migrants) are having more than 5% of prevalence.
As in other countries in the region, IDUs, MSM and FSW are the groups most at risk with highest HIV prevalence. Most cases of HIV occur among labor migrants (46%) and increasing number occur among their wives (a combined 21% of HIV cases in low-risk women in rural and urban areas). Of all adults estimated to be living with HIV, a major proportion of HIV infections has consistently been among migrant workers travelling to India for work. In 2005, 46% of estimated HIV infections in Nepal were among seasonal labour migrants and similar pattern is found in 2007. Clients of sex workers account for 19% of HIV infections in 2005 and 16% in 2007. Spouses or female partners of migrant workers and clients of sex workers, now account for 21% of all adult infections. A 2006 study among Nepali migrants travelling to Indian cities for work found that 27% of men engaged in high risk sexual behaviors while in India and frequent sex workers.

Estimated Population Living with HIV and AIDS

Population groups Adult living with HIV
IDUs 10%
MSM 4%
FSW 2%
Clients of SWs 15%
Seasonal labour Migrant 42%
Trafficked women returned to Nepal 1%
Sub-total at risk 74%
Urban female at risk 5%
Rural female at risk 21%
Sub-total low risk 26%
Grand total 100%
Source: Annual Report , DoHS Nepal, 2007/08

Epidemics analysis:
National estimates of adult HIV infection for 2007 is similar to the previous estimates with increasing numbers of the cases. National records show the high prevalence of HIV in certain sub groups; IDUs (34%), FSWs(1.4%) and their clients, MSMs(3.3%) and returning migrants(1.9%) and trafficked women. (DOHS Nepal, 2007/08)

Age distribution of the cases of HIV in Nepal:

Population subgroup Estimates
Children (0-14) 1,857
Adult (15-49)
# of Women LWHA 64,585
16,387
Adults (50+) 3,348
Total 69,790
Source: NCASC, 2009.

Epidemic Regions of HIV in Nepal (of the total cases):








Changes in the prevalence as indicated by IBBS in Nepal:
Prevalence in IDUs has dropped from 68% to 34% in recent years. Prevalence amongh FSWs among the terai district of highway of Nepal is also decreased significantly. In Katmandu prevalence amongh FSW has dropped from 2% to 1.4%.

National Actions
National level commitment:
MDG commitment: Government of Nepal has commitment on MDG 6 ( Combat HIV/AIDS ,Malaria and other diseases). MDG target no.7 states ,” Have halted by 2015 and begun to reverse the spread of HIV/AIDS”.

Second Long Term Health Plan (1997-2017): Essential health program intervention as defined in SLHTP has stated as priority issue of HIV and AIDS. Main intervention no. 4 includes condom promotion and distribution for STD/HIV, Hepatitis B and Cervical cancer prevention method.

Policy and programming:
The following documents reveals the national government leaderships with the help of civil society for combating the threat of HIV and AIDS;

1988 Launched the first National AIDS Prevention and Control Program (short term)
1990-1992 First Medium Term Plan
1993-1997 Second Medium Term Plan
1993 National Policy on Blood safety
1995 National Policy on HIV/AIDS
1997–2001 Strategic Plan for HIV/AIDS Prevention
2000 Situation Analysis of HIV/AIDS - Nepal December 2000
2002–2006 National HIV/AIDS Strategic Plan
2003-2007 National HIV/AIDS Operational Plan
2006-2011 New National HIV/AIDS Strategic Plan
2006-2008 National HIV/AIDS Action Plan

Activities at district level:
In the district level district (Public Health) office is the leading body to take the action. HIV and AIDS focal person as designated at D(P)HOs. Starting of a position as District AIDS Control Coordinator under leadership of District Development Committee( the local government body) and DHO has been the new action to coordinate all the activities carried out at district level.

Major activities carried out in Nepal
 BCC interventions to prevent infections
 Harm reduction
 Voluntary counselling and testing service
 Anti Retroviral Therapy
 Prevention of Mother to Child Transmission

Conclusion:
Being a concentrated epidemic country with inadequate policy and legal frame, there is always a problem of ownership problem at government level. The activities regarding HIV and AIDS are always led by civil society. Majority of the activities and policy farming were provided with in put by civil society. However, without a strong government leadership, MDG is unlikely to be achieved.

Monday, March 15, 2010

HIV scenario in Nepal

HIV History in Nepal:

First found in 1988, HIV started as behavioural disease in Nepal. Current estimates shows that not less than 70,000( Low estimate 50,000 and high estimate 99,000) people are affected in this small country (.03% land of the world).
Not until recently, people used to be shy to talk on this issue within the professional works. Not lay man but health workers, todate find uneasy to discuss in this issue in some of the health care setting.

HIV prevalence in Nepal:
UNICEF estimates overall prevalence in Nepal is 0.5%, women (MTCT) with HIV ))positive status is 17,000 (till 2007). The most vulnerabl groups are ID users, Migrant populations, Sex workers and housewives.
Prevalence in Young people is 0.5% in male and 0.3% in female. However, only 44% of the young people have comprehensive knowledge in HIV. Condom use among young people who have knowledg is only 78%.
Another most growing cocern is the transmission of the disease in houswives. The data shows 49% were housewives among all infected women (2005 estimates, MOHP). The other group shows about 20% prevalence in migrant.
The most cocerned route for leading this staus is sexual contact.


Some of the steps going on to check the concentrated epidemic:
MDG goal taken as given the highest priority in program of Nepal has targeted to halt the infection by 2015 and reverse by then, the spread of HIV. The followings are the some of the actions going on to reach the MDG;
- Establishising District AIDS coordination committee (DACC) at district health system and local governing body
- Focal point in district (public ) health office to support DACC
-National Control for AIDS and STI Centre (NCASC)
- A technical committee at national level to provide guidance for NCASC
- Starting of PMTCT in different government hospitals

(I)NGO and Multilateral support has been the leading action in all of the activities. Including prevention activities, care and support, PMTCT and leading Government activities.

INTRODUCTION and INTEREST

INTRODUCTION:

I am a public health worker in Nepal. I am basically affiliated to
child health program in Nepal. Mainly Community Based IMCI and
Community Based Neonatal care package. I have been affiliated to
Nepal Government for three year as Health Assistant(
clinical/paramedical), ADRA Nepal in RH coordinator, CARE
international as Project Officer, International Org. for Migration
(IOM) Data Management Assistant.

I have been involved in research in child health, HIV and maternal
health in Nepal. Apart from that based on my responsibility, I am
supposed to provided technical assistant to District Health Office,
and NGOs in our working area.

Currently I am doing Master of Public Health in Australia with major in Epidemiology and Biostatistics. I am also a graduate in Public Health and Masters in Sociology.
Geographically, I am from western part of Nepal ( Nearby LUMBINI, the
birth place of lord Budhha) , I am Aryan/Asian by ethnicity.

As, I was prmarily involved in child and maternal health during my carrier, I am really interested in increasing my horizon of knowledge and understanding on the HIV and AIDS related issue.

In HIV and AIDS my area of interest includes:
- HIV in vulnerable groups ( Migrants, Housewife and new borns: in context and requirement of my country)
- World successful public health model of pramming in these issues.