Going beyond official statistics and reports, what’s the threat of HIV/AIDS when issues like awareness and prevention is a key element in South Asia where talking about safer sex and say HIV/AIDS is still a taboo?
The question depends on how the country is coping with it. The UN can only provide assistance. It’s a key question we’re trying to address. The estimates from the last two years show a slight decline in some groups.
That’s the reason why the response in countries like Nepal often referred to as concentrated, mostly among high risks and vulnerable groups like sex workers, intravenous drug users (IDUs), men who have sex with men (MSMs), and also amongst migrant workers.
Women also fall under this category since they are vulnerable due to lack of knowledge and get infected by their spouses.
The response has to be in a multi-sectoral kind of way. It has to be treated as a developmental issue in which everyone should participate because if you want to change behaviors, the society has to change its behavior which can come about in several ways: individuals have to start realizing, they must have knowledge, information and means to protect themselves because AIDS can only be prevented if each individual realizes the risk and has the means to do so. Protected sex is the only way to prevent an infection except in the case of IDUs.
That requires major effort in society. That’s why leadership at all levels is extremely important. Various issues related to HIV needs to be talked about and not hidden behind the veil of culture, values and prejudices, which in fact tries to criminalize or stigmatize elements in society.
That’s why HIV/AIDS is such a difficult issue to address especially in regions like Asia where values and culture plays a major role. People do a lot of terrible things in the name of culture and values. But that has to change if you want to protect the whole population and yourself. So leaders—religious and other, have to very much be a part of the program. The media has to play an important role.
The laws are a starting point. In Nepal, laws regarding HIV/AIDS are still under preparation.
There are a lot of discussions in the parliament, which itself promotes awareness and if these parliamentarians should take that awareness and disseminate into the population during multiple occasions, not only on World AIDS Day. One time delivery of any message is not advocacy; they must do this consistently.
If anything a national issue like HIV where a major effort is required to change behavior and distribute information, it must be repeated at every possible occasion.
Unfortunately, we’re still not able to do that. In countries like Cambodia and Thailand, awareness was conducted at the prime ministerial level—they have spread the message consistently and then you see a change in attitude and decline among the infected.
Even there a change in total attitude has not come about as yet. They still regard IDUs as marginal. Nobody is suggesting that behavior should be condoned but what we are suggesting is that everyone in society should be aware having access to healthcare and treatment. That aspect must be protected; human right to health care must be protected.
Societies will eventually change their attitudes toward these things in their own way; that cannot be prescribed from the outside. For HIV/AIDS issues to be addressed, access to information, regarding treatment and care for everybody has to become a norm in society and you shouldn’t allow anyone to deny that access.
Countries are using litigation as a means for doing the same. In India, litigation is initiated by the Ministry of Health against discrimination towards transgender and MSM. In Nepal there are laws on equality to transgenders; that in itself is a change.
This necessarily doesn’t mean the population has accepted the same but it’s a starting point. So it’s a very key question.
Everyone wants to be protected but end up blaming the other for spreading the disease and not themselves. Unless everybody realizes that each individual behavior is important, the society at large will not change.
Nepal’s two million migrant workers are potential clients of sex workers. According to Nepal’s 2010 UN General Assembly Special Session report, labor migrants make up almost 40% of the total HIV infection. And with new highways connecting the country to India and China, the risk might only scale up. How do you analyze this scenario and what needs to be done by the government of Nepal?
The government of Nepal, along with organizations that can facilitate like International Organization for Migration, the Labor Ministry, these are all very important.
Pre-departure training needs to be conducted properly and not just as a paper transaction, which often is the case in many countries.
Workers should be specifically trained and informed about self protection and how they can have access to condoms and other means. And incase a person suspects as being infected, there should be places they can go to for immediate care because some amount of prevention is possible within the first 48 hours. But most people are not aware of that.
I’m going to try and discuss this in India with some counterparts.
Also young people think that one time sex will not infect or impregnate an individual, but are shocked incase the same occurs. So a message regarding awareness has to be conveyed numerous times to be internalized.
This leads to another major issue—especially with women and children getting infected. Do you think enough is being done and what should be done?
No. There is a big gap in the program here—prevention of mother to child transmission. Number of people who actually get access to treatment and care are small—20 to 30%. That should be a 100%.
We need to focus attention on that aspect of the program and on the vulnerabilities of women. Even returning migrants, if they’re men, infect their wives, which is a major issue. Women are much less informed. They don’t have negotiating power to negotiate sex or insist men to use condoms.
That area needs to be focused on and pushed at. The Ministry of Women’s Affairs, Ministry of Local Development must be involved.
Please elaborate on HIV/AIDS as a security issue?
Security aspect is being emphasized by many western writers and researchers. In a sense, it’s a security issue actually for the world, that there millions of travelers and the virus doesn’t see borders. It’s like all other epidemic; capable of crossing all borders.
That is one major reason for heavy financing from donors in western countries for HIV, since it can affect their countries as well because there is movement
of people.
It can pose security issues for individual countries as well. For example, even a prosperous country like [South] Africa where the World Bank study showed that their GNP has reduced by 30% or something, due to the impact of HIV.
The Asian Development Bank and UNDP has conducted a study on South Asia and there were projections that it could happen. If left unchecked, economies of major countries could suffer a set back. So they’re linking economic downturn with security issues.
There will be instability like loss of jobs, lack of employment; huge youth population in developing world can pose a security issue.
I’m hearing more and more HIV/AIDS and security link partly also to convince donors to continue their support for HIV/AIDS and secondly we’re seeing success globally because many high prevalence countries like Zambia, Kenya and Zimbabwe are all showing downturn among the infected population.
But still for every individual that goes for treatment, there are six new infections. We’re not winning the battle. Unless we have more people getting treatment and fewer infections, it’s not going to change the trend of the epidemic. That’s why the UN goal is to try to get to zero infection as soon as possible. We strive to get there.
Asia was considered a very low prevalence region and not much attention was given to it. I used to argue that Asia is such a huge population and that even a low prevalence level will result to large numbers and it was like a slow tsunami waiting to happen. India now has the second largest number of HIV cases in the world after South Africa.
Though the prevalence levels in India are really low but actual numbers that can move around the world are very high.
You can thus see why all countries are important in the fight against HIV. And there is a special strategy for low prevalence countries. They need to focus on drivers of the epidemic with most of their resource.
The most difficult kinds of things have to be done in low prevalence countries because that’s the only way to prevent it from becoming a real epidemic. Countries like India, Nepal, Pakistan, are not considered as high health priority but in terms of future, it can be high prevalence and you won’t even know it. Everything is an estimate but the actual number maybe even higher. That’s the danger.
Access to antiretroviral drugs (ARVs) is limited in poor countries of the region. And increasing ARVs means people are getting drug resistant and the treatment has to be changed into second-line ARVs, which are more expensive. So how will this work in achieving the MDGs?
That’s a huge issue. Once a person is on antiretroviral, they can have a normal life expectancy. So you might have to treat the person for 20-30 years. That’s a continuing, recurring expenditure.
There are many efforts on how to sustain that expenditure. Many projects are looking to distribute the expenditure between an individual, the state and external financing. We have to think of more innovative ways—reduce the cost of drugs and at the end reduce any new infections.
That’s the way to get the money allocated for treatment. It’s an issue that’s really quite important. That’s why donors are concerned that they might have to sustain high level of treatment if they want HIV/AIDS to be eliminated.
One thing we can push more is to help the infected become economically independent. Many infected by HIV don’t have regular employment. We have to motivate and push them to become part of mainstream employment system so as to sustain some of their own treatment and care.
At the moment, they get special jobs and are not necessarily working at normal places where they can work.
So this comes back to the first question: how do you get rid of prejudice, stigma, and discrimination? That’s one of the ways to make it sustainable because people after all pay for treatment.
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