"EPIDEMIOLOGICAL ANALYSIS OF HIV AIDS IN THE CONTEXT OF NEPAL”

SUBMITTED TO: Department of Public Health Faculty of Medical Sciences Nobel College Sinamangal, kathmandu Pokhara University

SUBMITTED BY: Anurag Sedai(04) Bipin Adhikari(12) Deepika Paudel(15) Pranita Sharma(24) Supriya wagle(37) GROUP "D"

BPH 2nd SEMESTER SUBMITTED ON: 9th September, 2009

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ACKNOWLEDGEMENT
We are privileged on receiving this opportunity to prepare term paper on “EPIDEMIOLOGICAL ANALYSIS OF HIV AIDS IN THE CONTEXT OF NEPAL” and we would like to express our gratefulness for entrusting us for this work. We would like to thank our seniors Miss. Sanju silwal and Miss Vinita Sharma for their guidance and instructions. We would also like to thank our respected teachers Mr.Subash Adhikari and Mr.Umesh Raj Aryal for their support. We would like to express our gratitude towards Mr.Shyam Shrestha and Dr. Shyam Lohani. We are indebted to all the teachers who helped us to prepare this term paper. We acknowledge the valuable support received from our friends. We will always be indebted to their important views and suggestions. This research paper would not have been successfully prepared without help of Nobel library which provided us with previous research paper and Annual reports. We in co-operation of computer lab of Nobel College and a number of individuals and organizations made our work easier. Group ‘D’ BPH 2nd semester.

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TABLE OF CONTENTS 1) Acknowledgement ii iv v 1-5 2) List of figures 3) Abstract 4) Introduction a) Background b) Statement of problem c) Purpose of study I) General Objectives II) Specific objectives Literature review e) Operational Definition 5) Methodology 6) Findings 7) Discussion 8) Conclusion 9) Recommendation 10) References 6 7-13 14-15 16 17 18 List of Tables and Figures: 3 .

Table 1: Cumulative HIV infection by age-group Table 2: The cumulative HIV infection by sub-group and sex Table 3: Condition of HIV positive including (AIDS) and AIDS (Out of total HIV) Figure 1: Showing detection of HIV/AIDS by sex (1988-2005) Figure 2: Sex distribution of reported HIV positive cases in Nepal Figure 3: HIV prevalence in female Sex workers in Different areas Figure 4: HIV prevalence in High risk Groups in Terai Highway districts Figure 5: HIV prevalence in IDUs 7 8 10 9 10 11 12 13 Abstract 4 .Page No.

sex workers in different areas. girl trafficking and HIV/AIDS incorporating some traditional ideas such as fatalism. Introduction a) Background 5 . Sex workers come from various backgrounds. it is also a development issue. because of the poor surveillance systems and the lack of access to quality voluntary counseling and testing services coupled with antiretroviral treatment these prevalence figures are likely to be a gross estimate. Although women play role of sex workers or in mother . AIDS will be the leading cause of death among 15-49 years old in the next ten years. health infrastructures and government. though the majority hail from the lower socio-economic class. availability of health services. The school education curriculum should include a separate subject on safe sex. According to the Centers for Disease Control and Prevention.to. .condom use. sex. This report reflects the HIV/AIDS status of different age group. sin of previous life etc. and are between 15 and 28 years old. identify the risk groups. most women acquire HIV from their sole regular partners and reducing acquisition of HIV among men is key to reducing the spread of HIV to women. The sex worker population is also highly mobile and heterogeneous. are married. selfmanagement. . By using mathematical models it has been estimated that there were more than 70.This study was conducted to know the epidemiological status of HIV/AIDS in Nepal. Most cases of HIV infection in Nepal are HIV-1. HIV/AIDS is a global pandemic that has created challenges for physician. Basically the study was launched to assess the trend of infection.child transmission. HIV infection in Nepal mainly occurred among 15-49 years. If trends continue. The duration of study was from 10th June to 9th September 2009. World Bank figures indicate that 1/3 of HIV infection nationwide is among drug users. However. The situation in relation to HIV in Nepal is different from when the first case was diagnosed in 1988. It is cross-sectional analysis.256 people living with HIV/AIDS in Nepal at the end of 2005. It was prepared being based on secondary data. sexual decision making skills. Women are more vulnerable than men. AIDS begins when a person with HIV infection has a CD4 cell count below 200 ("T-cells" or "helper cells of i"). AIDS is one of the deadliest communicable infections of twenty first century. subgroup like IDUs. drug abuse.STD’s. although HIV-2 was recently reported. HIV/AIDS is no longer only a health issue.

HIV/AIDS is a major public health concern regarding the further growth potential of it within different regions. As the virus attacks and causes destruction and weakening of the body’s immune defense system it’s known as HIV.414 cases of HIV infection were reported officially. The HIV and aids epidemic continues to grow worldwide. which attacks and destroys certain white blood cells that are essential to the body’s immune defense system. About 95% of all infection occurs in low and middle income countries. more than 2. 6 . an estimated 3. 18 million are women and 2. BPH 2nd semester.3 million people are estimated to be living with HIV and aids. less availability of health facilities and services and is open bordered with India which contributes to one of the largest group of HIV infected people globally. 40.e. Worldwide. Nepal is economically poor country having low literacy rate. HIV epidemics are largely concentrated among groups with high risk behaviors namely sex workers and their clients and IDUs. Human immunodeficiency virus (HIV) is a retro virus that can lead to Acquired Immune Deficiency syndrome (AIDS). epidemiology is the study of the patterns of diseases and factors that cause disease in man. HIV/AIDS though harmful to human being. Aids represent the late clinical stage of infection. By March 2009. That is why it is essential to be alert from unprotected and unnatural sexual behavior to achieve that goal awareness is essential. Therefore. the first case of aids was reported in Nepal in July 1988. present the global medical and public health communities with one of the most significant challenges.258 cases of full blown AIDS and over 13. Among them.4 million are sufferers during 2006. This pattern of devasting infection is caused by a virus. common. we can generalize that the span of HIV/AIDS is directly and entirely associated with the sexual behavior i. According to CDC. Currently it accounts for the highest number of deaths by any single infectious agents.8 million are newly infected adults.This term paper is prepared for the partial fulfillment of the requirements for the basic epidemiology. In Nepalese context. universal and natural behavior of human being. No other infection/disease has such an impact on humans than the degree of HIVAIDS does. it is fully preventable too. Primarily it is sexually transmitted diseases and other way of transmission is regarded as secondary.

which provide the potential for considerable sexual networking. For the controlling of spread of HIV infection government must recognize. it is estimated around 75. economic. give special attention and acknowledge the needs of high risk groups i. Recorded cases of blood and organ recipient are relatively low at around 0. and migrant workers. because of the poor surveillance systems and the lack of access to quality voluntary counseling and testing services coupled with antiretroviral treatment these prevalence figures are likely to be a gross estimate World Bank figures indicate that 1/3 of HIV infection nationwide is among drug users. women trafficking. Most cases of HIV infection in Nepal are HIV-1. homelessness.e. illiteracy. health infrastructures and government.256 people living with HIV/AIDS in Nepal at the end of 2005. prostitution. Most of the infected people are in the age group 20-39 years reflecting the highest reported number of HIV infection in the age group of 30-39 years. stigma. discrimination and gender based inequality.6%) followed by IDU (20. b) Statement of problem HIV/AIDS is a global pandemic that has created challenges for physician. The largest number of reported HIV infection come from men who have been client of sex workers (49.2%. legal and human rights factors affect not only the public health dimension of HIV/AIDS but also individuals physicians/health workers and patients.9%). By using mathematical models it has been estimated that there were more than 70.Female sex workers themselves form the largest group (8. in context of Nepal fear of stigma and discrimination is a driving force behind the spread of HIV/AIDS. drug users. There are extensive migration patterns both within the country and internationally.5%). commercial sex workers.000 people living with HIV/AIDS in Nepal. However. HIV infection in Nepal mainly occurred among 15-49 years. although HIV-2 was recently reported. AIDS will be the leading cause of death among 15-49 years old in the next ten years. If trends continue. Man y factors drive the spread of the disease. such as poverty. which adopts a multisectoral approach focusing on prevention among vulnerable 7 . The extent of AIDS epidemic in Nepal will depend upon rates at which sexual partners are exchanged by commercial sex workers and the men who regularly visit them.According to the global AIDS epidemic report 2006. The 2002-2006 HIV/AIDS strategy proposed by government. These social. due to recent conflict.

 To identify the risk group and vulnerable groups for HIV and AIDS. the family and the wide society according to Redcross. The general and specific objectives of our research are as follows: I) General Objectives  To assess the epidemiological analysis of HIVS/ AIDS in Nepal. availability of health services. identify the risk groups. The effect of HIV/AIDS operates at three different levels: the individual. c) Purpose of Study AIDS was first described in 1981. 1990. Sociologically HIV/AIDS epidemic is not only a health problem but also a social problem that has social and economic roots. II) Specific Objectives  To assess the prevalence of HIV and AIDS in Nepal. care and support. Since then. AIDS is a major global public health problem of this century and threat to human beings.  To assess the available services launched by government. In some parts of Africa. consequences and solutions according to lyon. AIDS is one of the deadliest communicable infections of twenty first century having no cure. d) Literature review This chapter deals with general and specific literatures on HIV/AIDS. and on voluntary counseling. Nepal is one of the countries having increasing burden of HIV infection that has lead to increasing number of AIDS cases.  To assess the status of HIV/ AIDS in the context of Nepal. on control.group. The onset of HIV/AIDS may bring a number of social. The study was made to identify the underlying caused and different factors that has aided in prevalence of the infection. Basically the study was launched to assess the trend of infection. 1993. and create target for achievement. HIV/AIDS is known as the “family disease” because it transfers from the parents to their siblings. Young people are the 8 . 1997. AIDS has become epidemic and pandemic as well. It could interfere the social life of a person infected by HIV/AIDS is an individual may tremendously affect the society and the nation as a whole according to Class. economic and psychological problems in the community and in the world as a whole.  To assess the relation of cross border issue in prevalence of HIV and AIDS.

infected needle syringe.e. Some of the surveys revealed that there is concentrated epidemic among injecting drug users and commercial sex workers according to WHO 2001. the HIV prevalence consistently exceeds 5 percent in one or more sub-groups. infected blood and blood products. B. any discussion on sex and sexuality is taboo. i. According to him.al. denial. Prevalence of HIV and AIDS: The number of persons in a defined population who have a Trend of HIV and AIDS: It refers to the frequency distribution of disease according to the HIV/ AIDS at a point in time. low levels of education and literacy. e) Operational Definitions A. four main modes of HIV spread are namely sexual intercourse. stigma and discrimination are major contributing factors to HIV vulnerability in Nepal according to Nepal UNAIDS 2003. Commercial sex is a cultural taboo and continues to be legal in Nepal..al. Poverty.‘window of hope’ is changing the course of the HIV/AIDS pandemic preventing HIV infections among them is vital of the 40 million people living with HIV/AIDS according to cluster 2001. Male sexuality expresses itself in such behaviors as ingratiating with girls in a manner that carries social overtones. In fact it is now apparent that Nepal has entered the stage of a “concentrated epidemic”. Homosexual relationships are reported to be rare. particularly in the rural areas according to Mugrditchian et. 1998. age group population. Usually the time of a survey is done. Husband and wife do not discuss sexuality and parents do not discuss sex with their children according to Upadhaya. 9 . gender inequality. premarital sex multiple sexual relationships. 1998. extramarital sex and polygamy. Among all factors in Nepal highest rate of HIV/AIDS is identified among the injecting drug users according to Jha. surgical instruments and infected pregnant women to her baby. Lack of knowledge and access to contraceptive as well as vulnerability to sexual arouse put adolescents at high risk of unwanted pregnancy.. 1999. In traditional Nepali cultures and societies. 1995 Women are often forced into sex work through the need for money to maintain their families and children according to Karki et. These include IDU’S national wide. returning FSW’S from India. FSW’S in urban areas.

D. vulnerability of certain population sub-groups to the infection.  Study Area: The study was conducted covering all areas of Nepal. F. It was prepared being based on secondary data. Stigma may be about race physical disability sex and sexual orientation.C. Risk and Vulnerability of HIV and AIDS: It denotes to the specific susceptibility of Stigma and Discrimination: Stigma is a social maker that labels people negatively as a Cross Border: It refers to across the Nepal-India border. Methodology  Study Design: It is cross-sectional analysis. 10 . deviant.  Study Duration: The duration of study was from 10th June to 9th September 2009. E. Migration: It refers to relocation or movement of people from one place to another.

Findings Table 1: Cumulative HIV infection by age-group as on February 12. The time limitation made it difficult to analyze other data so the report may cause biases.  Reliability and Validity: Data and information from reliable sources (published document) were used.  Limitation of Study: • • The study was only based on secondary data. 2008 11 . Study population: population of Nepal  Data Processing and Analysis: Data was processed and analyzed through Ms-Excel.

Age group(years) Male Female Total New cases in March 2009 0-4 5-9 10-14 15-19 20-24 25-29 30-39 40-49 50 above Total 190 222 78 246 1169 2027 3630 1069 258 8889 114 156 55 253 795 1065 1540 434 113 4525 304 378 133 499 1964 3092 5170 1503 371 13414 2 7 4 1 14 28 49 35 11 151 12 .

2008 is tabulated below Sub groups Male Female Total New cases in March 2009 Sex Workers(SW) Clients of SWs/STD Housewives Blood or organ recipients Injecting Drug Users Men having sex with men(MSM) Children Sub-group NOT identified Total 479 53 8889 321 26 4525 800 79 13414 13 2 151 28 2367 (17.8% ) 795 104 3221(24%) 11 47 799 5984 3221 39 2414** 78 4 48 61 1 18 4 13 . The highest prevalence of HIV/AIDS can be seen in the age group 30-39 which mostly includes economically independent and covers 27% of total HIV infected cases followed by 25-29 and 2024.Source: Ministry of Health and Population. Katmandu It represents the Cumulative HIV infection by age-group which is expressed in numbers. Table 2: The cumulative HIV infection by sub-group and sex as on February 12. National Centre for AIDS and STD Control.6%) 78 4 5880(43. Teku.

8% of total infection followed by housewives.IDUs or Sexual Source: Ministry of Health and Population.**Mode of Transmission. The numbers increased as the numbers of sex workers and intravenous drug users increased. Again the numbers decreased in the year 2005 as there was behavioral change in the use of safety methods like condoms during sexual activities and exchange of needles and syringes among IDUs. Figure 1: Showing detection of HIV/AIDS by sex (1988-2005) Source: annual report. Teku. National Centre for AIDS and STD Control. 14 . 2006 From the above chart. injecting drug users which accounts for 24% and 17. 2009 It shows Cumulative HIV infection by sub-group and sex. The prevalence of HIV/AIDS is highest in the clients of sex workers which contributes 43. it is seen that the numbers of HIV infected had increased drastically in the year 1997 because of lack of adequate knowledge about HIV/AIDS and diagnostic methods.6% respectively. Katmandu as on March 13. it has decreased after 1997 may be due to awareness about HIV/AIDS followed by increasing numbers up to 2004.

Teku. 2009 Figure 2: Sex distribution of reported HIV positive cases in Nepal 15 . National Centre for AIDS and STD Control. Katmandu) as on March 13.Table 3: Condition of HIV positive including (AIDS) and AIDS (Out of total HIV) Condition HIV positive including (AIDS) AIDS (out of total HIV) Male 8889 Female 4525 New cases in this month 151 1601(16%) 657(13%) 29 Source: Ministry of Health and Population.

Figure 3: HIV prevalence in female Sex workers in Different areas 16 .It shows condition of HIV in males and females as registered in Ministry of Health and Population who are HIV positive and turned into AIDS. 13% of HIV infected women have archived AIDS condition and 16% of HIV infected men have archived AIDS condition.

5% in 2006 Figure 4: HIV prevalence in High risk Groups in Terai Highway districts 17 .HIV prevalence among Sex workers in Kathmandu and Terai highway districts decrease from 2% to around 1.

Figure 5: HIV prevalence in IDUs 18 .Fig. Shows that HIV prevalence is more among labour migrants than in other high risk groups in terai highway districts. 4.

Discussion HIV transmission is very much related to sex.7%in 2005. This may be due to frequent exposure to 19 . Slightly decrease in Pokhara and EasternTerai in 2005compare to 2002. So the infection rate is very high in the reproductive age group (14-49 years) especially in the age group 30-39.Figure 5 shows HIV prevalence among Intravenous drug users was 68% in kathmandu in 2002 and declined to 51.

The alarming rise of the infection among women might also have been because the number of female sex workers is increasing. These people are freely mobile in the population and increase the chance of transmission of the disease. Intravenous Drug users 20 .5 percent. a major contributor to the spread of HIV in Nepal has been Nepal’s mobile population.5 percent). Women are more vulnerable than men. They are the ones who migrate to cities or abroad. Sex workers(SWs) and their clients b. most women acquire HIV from their sole regular partners and reducing acquisition of HIV among men is key to reducing the spread of HIV to women. Later. new subgroups continue to emerge like blood and organ recipients and children. sex workers 19. are married.8% of total infection. and are between 15 and 28 years old.child transmission. though the majority hail from the lower socio-economic class. Although women play role of sex workers or in mother . Sex workers come from various backgrounds. Different groups were first identified as vulnerable groups by NCASC.g. There are challenges to be addressed in the fight against HIV and AIDS. mostly to India to work. other sub-groups were added as sub-populations at higher risk but again. Shift in trend of age group with highest infection rate might have been due to increased migration rates. The sex worker population is also highly mobile and heterogeneous. They are mostly single meaning either unmarried or living without their wives. Nepal has a low prevalence for HIV and AIDS (0. According to annual report 2006. This change in risk and vulnerability might be due to the effect of the bridging population. As in India. The situation in relation to HIV in Nepal is different from when the first case was diagnosed in 1988. and intravenous drug users (IVDU's). According to NCASC the prevalence of HIV/AIDS is highest in the clients of sex workers which contribute 43. 68 percent. Due to these they are more likely to indulge in premarital or extra marital sex which makes them prone to HIV/AIDS. migrant population 4-10 percent. they transmit it to their wives-the bridging population through whom transmits to their future baby. The vulnerable groups for HIV/AIDS recognized by NCASC are as followsa. some groups show evidence of a concentrated HIV epidemic e.to. The perfect example of this is the increasing incidence of HIV in housewives and the clients of the sex workers. both in rural and urban areas. Once they come back.infection through regular unprotected sex with sex workers with high prevalence of infection. including truckers and migrant workers.

Sex-workers-street based and non street based c. community. Prisoners But now. Family members. 21 . MSM f. the population at risk is even broader due to the effect of bridging population. Tackling the epidemic will require not only prevention and control of HIV infection among vulnerable and risk groups. but a multi sectoral approach addressing the lack of access by risk groups to health care and education and recognition of the populations at risk People living with HIV and AIDS should be brought to the forefront in the fight against HIV/AIDS. IDUs b. The subpopulations at higher risk (PHR) include a. Mobile population d. it is also a development issue. Uniform service Conclusion HIV/AIDS is no longer only a health issue. Clients of sex-workers d. Street children h. Labour migrants/transport workers e.c. Partners of migrants/housewives g. Men having sex with men(MSM) e.

66% male and 34% female were infected with HIV/AIDS.4 % in the clients. 0.8% in children.5% in 15-19. Recommendations The school education curriculum should include a separate subject on safe sex. Poverty.1% in 20-24.7 in SWs.organizations. There was increase in total number of HIV/AIDS infected people.0. self-management. So the concerned authority should be devoted to reduce poverty. drug abuse. sexual decision making skills. and decreased by 0. when the study of HIV infection was made on the basis of sub-group and sex on 2008 and 2009. girl trafficking and HIV/AIDS incorporating some traditional ideas such as fatalism.7% IDUs. sin of previous life etc. 0.1.0. 0.1% in blood or organ recipient. gender inequality. Poverty. addressing gender equity. Similarly.3% in 5-9. 0. This includes recognizing fundamental rights such as access to health care and information. and effort to reduce sex trafficking.2% in MSM. If we compare the data between 2008 and 2009 published by NCASC. and decreased by 0. shifts in trend and cross border issues are the major factors contributing for the prevalence of HIV/AIDS in Nepal.2% in 30-39. and the government all have their own important role to play. which give rise to migration and Trafficking as well as propagate violent uprisings. If poverty can be eliminated. 1. and migration are interlinked.8% in 25-29 years.2% in 10-14. migration. In the year 2009. 69% male and 31% female were infected with HIV. As with all international declarations on HIV/AIDS. illiteracy and migration might be reduced. illiteracy. while there is no change in % in sub-group NOT identified. illiteracy. 0. It further requires addressing the root causes of poverty and inequality. In the year 2008. Infection increased in housewives by 3%. 22 . the infection of HIV in age group 0-4 by 0. 0.9% in 40-49. But there is also variation in the percentage of infection of male and female. there is need to take a strong human rights approach to combating the epidemic.3%.STD’s. The percentage of infection of male has decreased by 3% and the percentage of female has increased. donors. 1.condom use.

Nepal (Page no. National Centre for AIDS and STD Control (NCASC) 2.Gender inequality may act as a major cause of improper health seeking behavior. Department of Health Services (Annual report 2006) 23 and HIV/AIDS . all above the mentioned factors share some relationship with one another and determine the accessibility to health services. which in turn affects transmission. prevention and prevalence of HIV and AIDS in Nepal. There is no central point of reference for such materials. Dissemination of knowledge relating to HIV prevalence in Nepal is not coordinate. Inclusion of partners of migrants and housewives.51-59) 3. Thimi. also affect the recording and reporting system. Cross border issue is not just a political issue anymore. Stigma and discrimination. Education and literacy rate determines the formation. Establishing more Anti-retroviral therapy (ART) sites can no longer control spread of HIV and AIDS. structure and utilization of legal framework. which again relates to poverty in the country. Bhaktapur. HIV & AIDS IN THE SAARC REGION by SAARC Tuberculosis center(STAC). Its impact in increasing HIV cases in Nepal has shown how open border between Nepal and India shapes of the epidemiology of the disease in the country. Given the number of agencies involved. uniform service and street children under ‘sub population at higher risk’ by NCASC indicates how the concentrated epidemic is slowly taking a generalized form. Shift in trend of age group with highest infection rate might have been due to increased migration rates. formal coordination and dissemination of information is required. References 1. This shift has also dramatically increased the area of risk and vulnerability. Nobel Library Katmandu 4. Term paper on Social Epidemiology of HIV/AIDS (2006) in Nepal. The presence of bridging population is also playing a vital role in bringing about these changes. Moreover. Very less number of studies and researches has been performed to study the prevalence of HIV/AIDS in Nepal. related closely.

Krishna Nagar. Delhi.B. 2006. Website:. Rohan’s New Illustrated Medical Dictionary.I.5. A.T. Gupta and Gupta. 6.S publishers and Distributors.Google search on status of HIV /AIDS in Nepal 24 .

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