Young People and HIV/AIDS Young People at the Centre of HIV/AIDS Epidemic Young people aged 10-24 years constitute 32.5% of the total population of Nepal and have been identified as one of the groups most vulnerable to the growing HIV/ AIDS pandemic . The estimated HIV prevalence among young people (15-24 years) was 0.17% in males and 0.18% in females at the end of 2001 . Ever reported HIV/AIDS cases at testing centres indicate that the highest prevalence of HIV/AIDS is in the 20-29 years age group (Table 1). 2 1
The first few cases of AIDS in Nepal were reported in 1988. Limited surveillance data in Nepal indicate that the current HIV prevalence is around 0.55% (FHI, 2005). Until December 2005 the number of people infected by HIV was 5 828. Nepal, formerly considered a low prevalence country, has progressed into the category of a country with “concentrated epidemic” where HIV infection has increased significantly within the high-risk population like sex workers and injecting drug users (IDUs) (Table 2). HIV prevalence among female sex workers increased from 0.7% in 1992 to 17% in 2002 and crossed 50% among IDUs nationwide3.
Table 1: Cumulative HIV infection by age group (1988 to 31 December 2005) Age group (in years) Male Female Total New Cases in December 2005 1 5 1 4 21 58 70 17 4 181 30
Table 2: HIV prevalence in high-risk groups High-risk groups IDUs (Kathmandu Valley, 2005) SWs (Street based in KathmanduValley, 2002) STI patients (2000) Blood donors (nationwide, 2002/2003) ANC (2000) Estimates 52% 15.6%
0-4 5-9 10-14 15-19 20-24 25-29 30-39 40-49 50 + Total AIDS*
42 36 24 179 774 1 075 1 633 411 75 4 249 696
25 28 10 183 361 409 428 116 19 1 579 263
67 64 34 362 1 135 1 484 2 061 527 94 5 828 959
0.7-6.6% 0.44% 0.2%
Source: National Centre for AIDS & STD Control, Ministry of Health, Teku, Kathmandu, MoH, 2004-05
* Out of the total number of people living with HIV/AIDS Death: 286; new death cases in December 2005: 13 Source: National Centre for AIDS and STD Control, Teku, Kathmandu, MoH, Nepal, December 2005.
Young People Are Vulnerable to HIV & STIs The major transmission route of HIV in the country is heterosexual where sexually transmitted infections (STIs) form a significant part of the HIV epidemic. It is estimated that around 200 000 cases of STIs occur annually in Nepal. A recent study conducted by the Family Planning Association of Nepal indicates that though nearly a third of young people were aware of STIs, the knowledge on means of transmission and prevention was relatively low. The STI prevalence was 5% among adults, 3% among adolescents and 6% in 1
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Fact Sheet
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young women aged 20-24 years 4 . The Sentinel Surveillance data on cases of HIV among STI patients has also been showing a steady increase from 1% in 1992 to 3% in 2001 . 5
In Nepal, access to STD services is poor while the use of condoms for effective infection prevention is not commonly known, thereby leading to increasing incidence of sexually transmitted infections among young people.
Many Young People Are Especially at High Risk Girls and young women Like most cultures in South Asia, existing social norms in Nepal perpetuate deep-rooted gender inequalities in all spheres of social life making women more vulnerable to HIV. Girls and young women often have limited access to education and face restrictive cultural and sexual norms. Nepal has the lowest literacy rate in South Asia and large gender-based differences exist in education. Only 19% of women aged 15 years and over are literate compared with 54% of men of the same age. Literacy rates and gender differences for the younger age group are only marginally better with 26% of boys and 51% of girls in the 10 to 19 years age group being illiterate6. One fourth of the estimated more than 60 000 people living with HIV/AIDS in Nepal at the end of 2003 were women7. Early marriage, which is common in Nepal, further undermines the health and well-being of young women. Almost half of all young women aged 15-19 years are already married (Figure 1). According to the 2001 Census, the proportion of married girls in the 1019 year age group was two and a half times more compared to the married boys in the same age group8. Further, negotiating for safer sex with their husbands is not a common practice among married women in Nepal, placing wives of men engaged in unsafe sexual practice and injecting drug use at risk of HIV and other STIs. Biological, social and economic factors together make girls and young women more susceptible to HIV. Rigid social norms deprive girls of life skills, support systems and the means to protect themselves or negotiate and adopt safer sexual practices.
Young sex workers Poverty, migration, conflict, trafficking of illicit drugs and prostitution are the major contributory factors to Nepal’s HIV/AIDS vulnerability. A large number of Nepalese girls are trafficked to Indian cities and many young Nepalese males working in India frequent female sex workers in both countries. Apart from the increasing number of HIV infections among persons with high-risk behaviour in Nepal there are also growing numbers of Nepalese female sex workers who have been infected with HIV in India and who have returned or will return to Nepal3. It is estimated that as many as 70% of sex workers returning from India were HIV-positive. There is no national statistic for HIV prevalence among young sex workers but there are fears that the figure is growing9. Though, there are no red light areas or brothels in Nepal, commercial sex work is prevalent in many towns, border areas and highways. Studies show that several girls as young as 13 years of age and young
Figure 1: Age at marriage Married by 15 Married by 18 Married by 20 19% 25%
60% 68%
married women sell sex. A study in Pokhara on female sex workers revealed that 59% of them were young 76% 82%
girls aged between 10-19 years. In Jhapa district, 31% of the female sex workers were adolescents10. A survey in Kathmandu in 2000 revealed the increasing prevalence of HIV in sex workers. While only 2.7% of sex workers were HIV-positive in 1996, the survey 90
0
10
20
30
Percent
40
50
60
70
80
Girls 20-24 years
Girls 25-29 years
Source: Nepal DHS 2001
2
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Cultural, economic and social constraints of young female sex workers limit their access to accurate information about HIV/STIs, sexual health and medical services.
sex partners, female partners in particular. It was found that 55% of the MSW and 65% of the MSM surveyed perceived little or no risk of HIV (Figure 3). The study concluded that MSM should be considered as an emerging group at risk of HIV because of their multiple sexual partnerships and high levels of unprotected sexual activity. It also indicated that MSM could be serving as a “bridging group” of HIV transmission to the general population.
Young men who have sex with men (MSM) Though no age-specific national data is available on young men who have sex with men (MSM), studies in Nepal reveal that sex between men seems to be relatively common, particularly within Kathmandu5. The Monitoring the AIDS Pandemic (MAP) Report 2005 revealed 2% of the tested MSM (199) to be HIVpositive in Kathmandu. This hidden community neither has the knowledge nor practices safe sexual behaviour when having sex with their male partners. They generally identify themselves as heterosexuals and are often married, putting their spouses at high risk of being infected with HIV. An Integrated Bio-Behavioural Survey (IBBS) in Kathmandu Valley conducted by NCASC, FHI, USAID, CREHPA, SACTS and BDS – which had a large majority of the sample representing young MSM (59% Male Sex Workers-MSW and 61% MSM were aged between 16-24 years) - showed an HIV prevalence of 4.8% in MSW and 3.6% in MSM. The survey also revealed high prevalence of STIs among them (Figure 2).
Figure 3: Extent of HIV risk perception among MSM 80 70 60 55 65
Percent
50 40 30 20 10 0 Little or no risk MSW Some risk MSM High risk 28 26 17 9
Source: Integrated Bio-Behavioural Survey (IBBS) in Kathmandu Valley- NCASC, FHI, USAID, CREHPA, SACTS & BDS, Nepal.
Young injecting drug users (IDUs) HIV prevalence among people injecting drugs soared from 2% in 1995 to nearly 50% in 1998. Half of the country’s 50 000 people injecting drugs were 16-25 years old11. A study by FHI, New Era and SACTS (2002-2004) revealed high HIV prevalence among IDUs aged between 15-19 years. The HIV prevalence was 26.2%,4.3% and 18.4% in Kathmandu, Pokhra and Eastern Terai respectively (Figure 4). Another study found more than a fifth (21%) of the
Figure 2: Prevalence rate of HIV/STI/HSV-2 among MSW & MSM in Kathmandu Valley 80 70 60 54
Percent
50 40 30 20 10 0 HIV + MSW STI+ MSM HSV-2+ 4.8 3.6 19 8.4 28.9
IDUs in Kathmandu, one eighth (13%) in Pokhara and a tenth (10%) in Eastern Terai to be adolescents. When contacted for an in-depth study about their injecting practice, networking and sexual behaviour, almost all of them reported smoking cigarettes as the entry into the drug habit. (FHI/CREHPA, 2001, 2002, 2003). Studies reveal that the average age of initiating drug use and IDU is 17 years. Behavioural research among
Source: Integrated Bio-Behavioural Survey (IBBS in Kathmandu Valley- NCASC, FHI, USAID, CREHPA, SACTS & BDS, Nepal.
Assessing the risk behaviour among MSM, the survey revealed that the sexual networks of the MSM population were highly diverse and included sexual links with the wider heterosexual population.
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revealed the corresponding figures to be 17.3% in 20005.
Consistent condom use was low with all categories of
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Figure 4: HIV prevalence among IDUs in Nepal 2002-2004 80 70 60 50 40 30 20 10 0 68
Figure 5: Increasing percent of IDUs injecting drugs at the age <20 years 80 70 60 50 40 30 20 10 0 64 51 46 45 53 68
Percent
35 22 26.2 18.4 4.3
Percent
Eastern Terai HIV + (All ages) Kathmandhu Pokhra HIV + (15-19 years old) Eastern Terai
Kathmandu 2005
Pokhra
2002-03
Source: FHI/ New ERA/SACTS 2002-2004
Source: Integrated Bio-Behavioural Survey (IBBS), NCASC USAIDS, SACTS and FHI, Nepal, 2005.
IDUs in Nepal clearly indicates that needle sharing, a major risk factor for HIV, is common. In one study, nearly two thirds of the IDUs (41 of 63) from Kathmandu said that they share both syringes and drugs with their group. The rest reported that though they did not share with group members currently they did so in the early stages of injecting. Most individuals shared with two or three members of their group and in some cases reported going to different groups regularly (FHI/CREHPA 2003).
and 33% to 42% in Pokhara in the past 12 months. Consistent condom use with different sexual partners had also declined in the past 12 months (Figure 6). A large number of IDUs were still at risk due to practices such as sharing needles and sharing drug solutions from a common container.
Figure 6: Decline of consistent condom use with different partners in IDUs (2002-03-2005) 80 70 60 50 40 30 20 10 0 60 50 34 40 30 9 12
Percent
According to another study, young IDUs were sexually active and had multiple sex partners. Approximately 78% had their sexual debut when they were less than 20 years old. Consistent condom use was low with regular as well as non regular partners, increasing their sexual partner’s risk to HIV5. An Integrated Bio Behavioural Study (IBBS) among 1 245 IDUs in Eastern Terai, Kathmandu Valley, Pokhara Valley and Western to Far Western Terai conducted by NCASC, USAID, SACTS and FHI (2005) revealed that more than 40% of IDUs were below 25 years of age. The HIV prevalence was very high in the places surveyed, with figures of 51.7% in Kathmandu Valley, 31.6% in Eastern Terai, 21.7% in Pokhara Valley and 11.7% in Western to Far Western Terai. Comparisons between the first round (2002-03) and second round (2005) findings of the survey revealed that a higher percentage of IDUs had started injecting drugs at a younger age (Figure 5). It also revealed that sexual contact of the surveyed IDUs with female sex workers had increased from 22% to 26% in Eastern Terai, 13% to 21% in Kathmandu 4
50 41
54 48 35
28 12 11
24 19 13
Eastern Terai
Kathmandu Regular (2005) FSW (2002-03)
Pokhra Non regular (2002-03) FSW (2005)
Regular (2002-03) Non regular (2005)
Source: Integrated Bio-Behavioural Survey (IBBS), NCASC USAIDS, SACTS and FHI, Nepal, 2005.
Conflict and young people Nepal has faced protracted political conflict for over a decade which forcibly displaced thousands of people, mostly young, both internally as well as across the border. Displacement from their place of origin puts young men and women at a high risk of STI and HIV. In the temporary shelters that they have to put up in, there is shortage of information and services, including protection measures against HIV, pregnancy and other STIs. They are also at risk of being raped and sexually manipulated. Further, the mobility of young people in search of means of survival in neighbouring India and other countries is also on an upswing. Migration of these young people without adequate information,
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a higher risk of HIV. In some cases, young men in the family migrate leaving their wives and children back home. These women are also at risk of practicing commercial sex in the absence of any other livelihood support in order to feed themselves and their children
also reports that have shown that a number of young women displaced to the cities are practicing commercial sex in hotels and restaurants as a means of livelihood.
Why Young People Are More Vulnerable Early initiation of sexual activity Sexual activity begins early for young people in Nepal. The sexual debut for the vast majority of girls occurs between 15 and 16 years and often within the context of marriage. Recent behavioural data indicates wide gaps between new emerging norms and existing cultural ones. A survey of 1 400 young people in seven different districts of Nepal showed that almost 20% of teenagers considered premarital sex as ‘proper’. One in five boys and nearly one in 10 girls interviewed in the survey were sexually active. Two-thirds (65%) of the boys said that they had used condom while 74% of girls claimed that their partners used condoms. Unprotected sex led to a 22% STD infection rate in boys and 13% in girls and caused pregnancy in 14% of the cases. The survey also showed that 13% had taken drugs while 5.4% injected them5. A survey among young factory workers in Kathmandu revealed that sexual activity among unmarried girls and boys and with non-regular partners was common12. Twenty per cent of unmarried boys and 12% of unmarried girls aged 14-19 years were sexually active. The mean age of sexual debut was 15 years and was the same for both boys and girls. A majority of young factory workers did not perceive themselves to be at the risk of contracting HIV. Sexually risky behaviour among resident and nonresident young men was found to be prevalent in five border towns of Nepal5. A significant proportion of young unmarried residents (54%) and non-resident (40%) men in the age group of 18-24 years engaged in sex with a non-regular partner. A large majority of nonresident young men (67%) cited a commercial sex worker as their last casual partner. A higher proportion of the married, non-resident young men (46%) got involved in casual sex in comparison with their A knowledge, attitude and practice survey reveals that though Nepalese young people are highly aware of the risk of HIV, this awareness does not necessarily translate into safe sexual behaviour13. Although an overwhelming majority (92%) of teenagers had heard about HIV/AIDS, only 74% of them knew that they should use condoms to protect themselves from HIV and only 69% said they should not have sex with commercial sex workers. 5 unmarried, non-resident counterparts (18%). Regular use of condoms during sex with non-regular partners was generally low and only a small proportion of them considered themselves to be at risk of contracting STDs and HIV.
Young people lack information and skills A number of studies conducted in Nepal indicate that awareness about HIV/AIDS among adolescents and youth is high. The Family Health Survey of 1996 reported that 82.6% of 15-19 year old women and 80.8% women aged 20-24 years answered in the affirmative when asked “Can a healthy-looking person have AIDS virus?” (MoH, Nepal, 2002). Knowledge on modes of transmission of HIV was also found to be high among adolescents and youth in different studies (UNAIDS and UNICEF, 2001, VaRG/ UNFPA, 2005). According to the Nepal Demographic Health Survey of 2001, more than 86% of young men and 52% young women between the ages of 15-19 years had heard of HIV/AIDS. Nearly half (42%) of all young women surveyed and 81% young men believed that there was a way to avoid HIV transmission. For the age group of 20-24 years, 55% women and 87% men had heard of HIV/AIDS and 44% women and 84% men of this age group believed that there was a way to avoid its transmission (Figure 7).
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skills and support in foreign lands also places them at
and this too exposes them to the risk of HIV. There are
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Figure 7: Knowledge about HIV/AIDS
services about sexual and reproductive health issues. Little sex education is offered in schools and sex and reproductive health are topics not openly discussed in families. Girls are in a more vulnerable position because
87.2 Have heard of AIDS 55.4 86.2 52.1
they have less access to formal institutional structures such as schools and health care systems than boys and are unlikely to be incorporated into or receive accurate information through informal communication networks 6.
Believe there is a way to avoid HIV 0 10 20 30 40
84.3 44.1 80.8 42.3 50 60 70 80 90 100
Figure 8: Knowledge of source and use of condoms Use with any partner
Percent 20-24 years (M) 15-19 years (M) 20-24 years(F) 15-19 years(F) 7.4 9.2
Source: Nepal DHS 2001
Data from the Nepal Demographic Health Survey (2001) shows that though a large majority of young people know where to get condoms, there is a major difference between this knowledge and condom use. While more than 95% of 15-19 year old males were aware of a place to source condoms, less than 10% used it with any partner (Figure 8). Existing data indicate that young people do not have adequate access to appropriate information and
Use with cohabiting partner
6.6 7.7
91.5
Know a source 0 10 20 30 40
78.2 95.1 67.3
50 60 70 80 90 100 Percent 20-24 years (M) 20-24 years (F) 15-19 years (F) 15-19 years(M)
Source: Nepal DHS 2001
Focusing on the Young to Halt the Spread of HIV/AIDS The first National AIDS Prevention and Control Programme was launched by the Royal Government of Nepal in 1988. This programme, known as the Short Term Plan for AIDS Prevention and Control formed the basis for the First Medium Term Plan 1990-92. The Second Medium Term Plan for AIDS Prevention and Control in Nepal was formulated to cover the years 1993-97. In 1995, Nepal adopted a national policy for HIV/AIDS prevention with 12 key policy statements. These included priority to HIV/AIDS and STD prevention programmes; the need for multisectoral and decentralized response; acknowledgement of NGO implemented programmes; coordination; evaluation; services for people living with HIV/AIDS; a non discriminatory approach; confidentiality for test results, and blood safety. 6 The National Centre for AIDS and STD Control was formed within the department of health for the implementation of the HIV/AIDS prevention programme. Based on the National Policy, a “Strategic Plan for HIV and AIDS in Nepal” for the period 1997 to 2001 was developed and adopted. It tried to operationalize the national policy and define key activities for each policy objective. Recently Nepal also established a “National AIDS Council” chaired by the Prime Minister. The overall objective of Nepal’s strategy for HIV/AIDS is to contain the HIV/AIDS epidemic in the country. The vision of the National Strategy is to expand the number of partners involved in the national response and increase the effectiveness of the response. It will do this by focusing on activities within priority areas, thereby optimizing prevention and reducing the social
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In 2000 Nepal also adopted the National Adolescent Health and Development Strategy in order to address adolescent-related issues. The basic strategy aims to increase access and utilization of adolescent friendly health services to young people. Nepal’s National HIV/AIDS Strategy 2002-2006 has been designed to guide the expanded response to the epidemic in Nepal. Priority areas include the prevention of STI and HIV infection among vulnerable groups and new infections among young people. The focus here will be on creating a supportive policy and community environment. The objective is to create a supportive environment for behaviour change among young people by increasing the understanding among decision-makers at all levels and communities about young people’s needs and behavioural patterns.
identified young people as one of the high-risk groups for HIV prevention. Various awareness-raising activities are underway with particular focus on schoolchildren, college students, school dropouts and other groups. Information, education and communication programmes through television, radio, newspapers, training programmes and workshops and distribution of booklets, brochures and similar literature are youth-targeted. Voluntary counselling and testing services are being provided from 50 sites, and reported regularly to the National Centre for AIDS and STD Control. Antiretroviral treatment is being provided from three hospitals: TEKU Hospital, Bheri, Zonal Hospital, Nepalgunj, and BPKHS, Dharan, and few NGOs and private service providers such as Nava Kiran Plus, Maiti Nepal, SPARSHA, Blue Diamond Society, and Yeti Chem. Currently, a total of 316 HIV/AIDS cases are on ARV treatment (CEPRA, 2005). Prevention of mother-to-child transmission (PMTCT) programme is available in three hospitals: Maternity Hospital, Bheri Zonal Hospital and BPKHS Dharan. HIV/AIDS has been included as one of the main issues in the 10th Development Plan which covers the period of 2002-2006. National Operational Plan for HIV/AIDS Control 2003-2007 has also been developed. The mission statement of this plan is to “begin the reverse of the spread of HIV/AIDS by 2005” by working with partners to increase effectiveness of the response (NCASC, MOH, 2003). The response to HIV/AIDS in Nepal, especially for young people, has been limited. An Adolescent and Youth Section has been established within the Ministry of Health and Population and is in the process of developing policies and programmes for youth. As there are very few adolescent and youth friendly health services in the districts, UNFPA through the UBW ‘Youth Friendly Services to prevent SRH and HIV/ AIDS in Nepal’ has initiated the process to deliver a comprehensive package to young people. This package includes providing information and services, including voluntary counselling and testing, in two districts in Nepal. An integrated reproductive health and
Strategies
• Establishment of a mechanism for joint consultation between ministries, local authorities, NGOs, trade unions, educational and support institutions, private sectors, CBOs and young people on policy-making and programming affecting young people.
• Advocacy for the needs and rights of young people with focus on policy-makers, decision-makers, parents and communities.
• To conduct qualitative research about the determinants of young people’s behaviour.
• Promoting awareness and behaviour change communication with the objective of empowering young people with the knowledge and life skills on how to avoid HIV and sexually transmitted infections.
• Providing youth friendly services with the objective of increasing the accessibility and availability of youth friendly and gender sensitive services with an emphasis on information about reproductive health and sexuality.
• Enhancing young people’s knowledge about HIV/ AIDS and methods of prevention in formal and nonformal education settings.
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impact of HIV/AIDS in the most cost-effective manner.
The National HIV/AIDS Strategy of Nepal has
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information service is being provided to young people in 19 districts through the Reproductive Health Initiative for Young People in Asia Nepal. Among the other organizations working on HIV and young people in the country are: WHO, UNICEF, Nepal Red Cross
Society, Family Planning Association of Nepal [FPAN], RHIYA NGOs, SOLID Nepal, Adventist Development and Relief Agency [ADRA], Save the Children US, CARE Nepal and the British Nepal Medical Foundation.
References : 1. Central Bureau of Statistics. Miscellaneous publication sheets, 2001 Census data. Kathmandu, 2002. 2. Health-related Millennium Development Goals : update after the high-level plenary meeting of the United Nations General Assembly (September 2005) : report by the Secretariat . EB 117. Geneva: World Health Organization, 2006. 3. Epidemiological fact sheets on HIV/AIDS and sexually transmitted infections - Nepal, 2004 updated. Geneva: UNAIDS, UNICEF, WHO, 2004. 4. Nepal project document: regional workshop on models for scaling-up youth friendly services for SRH&HIV prevention in South Asia, 12-13 September 2005. Kathmandu: UNFPA CST for South &West Asia, 2005. 5. The HIV/AIDS/STD situation and the national response in Nepal: country profile. Kathmandu: UNAIDS, NCASC, 2004. (Accessed 1 Sept 2006: http://www.unaids.org.np/uploads/publication/20060108133717.pdf ). 6. Mathur, Sanyukta; Mehta, Manisha; Malhotra, Anju. Youth reproductive health in Nepal: is participation the answer? Washington: International Centre for Research on Women, 2004. (Accessed 1 Sept 2006: http://www.icrw.org/docs/ nepal_0104.pdf#search=’Youth%20reproductive%20health%20in%20Nepal%3A%20is%20participation%20the%20answer’ ) . 7. National estimates of adult HIV infections Nepal 2003. Kathmandu: NCASC, Ministry of Health, 2004. (Accessed 1 Sept 2006: http://www.fhi.org/NR/rdonlyres/en7dr3ytcz4v7zo4aogyh23kpj4vzmiokbzusdt2khr4b2mgzzislju53quawsi2 67m7dfm6xxhkfd / nationalestimatesadulthivnepal2003no.pdf ). 8. Population Monograph of Nepal Vol. II. Kathmandu: Central Bureau of Statistics, 2003. 9. Nepal’s National HIV/AIDS strategy 2002-2006. Kathmandu: UNAIDS, 2003. (Accessed 1 Sept 2006: http://www.unaids.org.np/ uploads/publication/20060111035142.pdf ). 10. Family Health Division, Ministry of Health. Adolescent health and development in Nepal – A country profile 2005. Kathmandu, 2005. 11. Young people and HIV/AIDS : opportunity in crisis. Geneva: WHO / UNICEF / UNAIDS, 2002. 12. Puri M. Sexual risk behaviour and risk perception of unwanted pregnancies and sexually transmitted diseases among young factory workers in Nepal. Kathmandu: CREHPA, 2001. (Accessed 1 Sept 2006: http://www.fhi.org/NR/rdonlyres/ ehrxlfgbyfcg2k4ma7wdekizqooo5styhdsfi4o53xz6yzfxjpkqperclhwzo6bvqcfnmc6ar4lxqf/STDfactoryworkers1.pdf ). 13. A survey of teenagers in Nepal for life skills development and HIV/AIDS prevention. Kathmandu: UNAIDS, 2001.
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