363Review ArticleHIV and conflict in Nepal: Relation and strategy for responseKarkee R, Shrestha DBSchool of Public Health, BP Koirala Institute of Health Sciences, Dharan, NepalAbstractConflict and displacement make affected population more vulnerable to HIV infection. Refugees and internallydisplaced persons, in particular women and children, are at increased risk of exposure to HIV. In Nepal, there isconsiderable increase in the number of HIV infection since 1996 when conflict started. Along with poverty, stigmaand lack of awareness, conflict related displacement, economic migration, and closure of HIV programmes haveexacerbated the HIV situation in Nepal. Government has established “National AIDS Council” and launchedHIV/AIDS Strategy. The strategy has not included the specific needs of displaced persons. While launching an HIVprevention programme in the conflict situation, the guidelines developed by Inter Agency Standing Committee(IASS) are important tools. This led to suggestion of an approach with implementations steps in the case of Nepal inthis report.Key words: HIV, Conflict, Nepal, Response1. Relation between AIDS and ConflictDurban declaration pointed out that many of thelargest conflict affected population in the world werelocated in regions with high rates of HIV prevalence1.In fact, it is now well documented that conflict,displacement and poverty make affected populationmore vulnerable into HIV transmission2,3,4. However,this vulnerability does not always translate intoincreased rate of HIV transmission. Some situationsassociated with conflict such as increased isolation ofcommunities due to destroyed infrastructure andtrade; increased death rates among high risk groups;decreased casual sex associated with trauma anddepression may decrease HIV transmission5. Thus,whether or not conflict and displacement increaseHIV transmission depend upon various competingand interacting factors that may produce variedepidemiological patterns6.In general, there are many evidences which suggestthat Refugees and Internally Displaced Persons(IDPs), in particular, women and children, are atincreased risk of exposure to HIV infections withincreased prevalence of HIV in conflict affectedpopulation7, 8. Persons who are forced to leave theirhome and have crossed international border areRefugees while those who have not crossed theinternational border but displaced within their owncountry are known as Internally Displaced Persons(IDPs). The main route of HIV infection in complexemergencies is sexual transmission. Sexualtransmission is facilitated in a number of ways suchas (i) increased sexual violence and rape bycombatants (ii) increased interaction among militaryand civilians (iii) increased use of sex as acommodity by women and girls due toimpoverishment (iv) the breakdown of family, social,and/or cultural structures and consequent loss ofnorms that regulate sexual activity in stable condition(v) decreased availability and utilization ofreproductive health and other health services9.In Nepal, there is considerable increase in the numberof HIV infection since 1996 when conflict started10.This implies a positive relationship of conflict withHIV/AIDS. There are three main ways through whichconflict has contributed to the rise of HIV prevalence.Firstly, women and girls who are internally displacedto urban areas have been forced in sexual barteringfor survival. Displaced women and girls end upworking as cheap labourers in carpet factories, brickkilns, stone quarries and small motels. Even suchlow-grade jobs are hard to find and on the other handthey are offered jobs as waitress in various types ofrestaurants.CorrespondenceMr.Rajendra KarkeeSr.InstructorSchool of Public Health,BP Koirala Institute of Health Sciences, Dharan, NepalEmail: firstname.lastname@example.orgKathmandu University Medical Journal (2006), Vol. 4, No. 3, Issue 15, 363-367
364Once they begin their work, they are asked toentertain male clients in different ways. Now theyhave no other choices for survival and no legalposition to complain other than adoption of sexualexploitation. That is how the motels and cabinrestaurants are running sex business in urban areas. Inother words; displacement has helped sex industry toflourish and HIV to increase. Sex-workers haveconsistently been identified as populations withincreased rates of HIV. The prevalence rate of HIV infemale sex workers in Kathmandu increased from 2.7% in 1997 to 17 % in 2000.10The number of Cabinrestaurants in Kathmandu increased sharply since1996. It has been estimated that there are about onehundred cabin restaurants where more than 50,000women are working as waitresses11. Since most of thegirls and women come from rural areas and areilliterate, they are not aware of the disease and itstransmission routes. Even if they know, they canhardly negotiate safer sex with the male clients who,in most cases, are also from lower socio-economicstatus with similar knowledge about AIDS. Similarexamples of increased sex exchange for survival havebeen reported from other parts of the world duringconflict period. For example, in Ethiopia, theprevalence of HIV infection among Female SexWorkers (FSWs) in Addisaaba increased from 20%in 1988 to 54% in 1990 and to 73.3% in 1998corresponding to conflict related displacement andseparation of families12. In eastern and central Sudan27% of single mothers had become sex workers toearn living2.Secondly, people get separated from their familieswhen they, often unaccompanied by their spouses,migrate from conflicted-affected areas to non-affected areas. In Nepal, conflict has dramaticallyaccelerated the traditional economic migration ofmales from rural and hills to urban centres of Nepal,India and Gulf countries. The villages were left withmainly women, children and elderly. Thousands ofmen and adolescents had crossed the border to India.At the end of 2002, some 8,000 people crossed theborder every week13. Indian Embassy officials havereported that some 120,000 displaced Nepalesecrossed into India during January 2003 alone13. Astudy conducted by the Save the Children Norway-Nepal (SCN-N) states that 16,871 children enteredIndia for safety and in search of opportunities duringthe three-months span of July 4-October 4 in 200414.This was the period when government forces carriedout offensive operations on rebel hideouts in WestNepal. Though there is not official documentation ofmigration of Nepalese people to India, the estimate isthat there is at least 1.3 to 3 million Nepalese migrantworkers in different cities of India and the numbers iscontinuously rising15. There has been report thatmany visits sex workers in India and then bring backHIV home on their return. The disease then is knownas “Mumbai Disease” in Nepal16.Thirdly, the conflict has affected HIV/AIDSprogrammes and general health services delivery.Health services are severely under-resourced andhealth workers are frightened to work17. HIVprevention and awareness work has declined inNepal18. Many NGOs based in the capital city ofKathmandu are withdrawing their HIV/AIDS supportprogramme from districts and rural areas at the timewhen such areas need even more help and response inemergency situation19. A programme had managed toreduce stigma of AIDS in one of districts of westernNepal by enlisting many volunteers. Then, most ofthe district has been under Maoist control. All NGOoffices have been burnt down, infrastructure andgovernment offices have been destroyed. Staff andvolunteers are afraid to work and the programme’simpact is under the threat20.2. Government Response to the situationNepal has established “National AIDS Council”chaired by the Prime Minister. The council withrepresentation from government, non-governmentorganization, private sector and civil society will takethe lead in policy making and will advocate for multi-sectorial participation in the fight against HIV/AIDS.The council has endorsed the National HIV/AIDSstrategy (2002-2006), which is as follows21.• Prevention of Sexually Transmitted Infections(STIs) and HIV infection among the vulnerablegroups• Prevention of New Infection among the young-people• Ensuring care and support services are availableand accessible for all people infected andaffected by HIV/AIDS• Expansion of monitoring and evaluation framethrough evidence based effective surveillanceand research• Establishment of an effective and efficientmanagement system for an expanded response,This strategy seems very broad and no specificapproach has been targeted for displaced peopleespecially young women and economic migrants tourban areas to help in their survival and prevent risksof HIV/AIDS infection. Authorities have tried toinhibit the running of Cabin Restaurants, take actionon the managers and even to the girls. Withoutalternative livelihood activities or other prevention
365programs, closure of restaurants or deprivation ofgirls to work would not solve the problem.3. Recommended Strategy3.1 Approach and rationalHumanitarian organizations have paid more attentionto basic needs such as health, water, shelter and foodand did not include HIV issues in their priority in thepast. Recent studies showed that people affected bycomplex emergency had high vulnerability to HIVtransmission and that HIV itself could be anemergency9. Studies also showed that links of HIVwith complex situation are diverse and complex.Therefore, a multisectoral approach with nationalframework is needed to tackle the problem. Variousinternational agencies have developed the guidelinesto address the HIV problem in complex emergencies.Inter Agency Standing Committee (IASC) is one ofthem, which has produced such guidelines. The IASCis an interagency forum for co-ordination, policydevelopment and decision making in the area ofhumanitarian assistance. The IASC was establishedin June 1992 in response to United Nations GeneraAssembly Resolution on the strengthening ofhumanitarian assistance. The IASC is composed ofvarious United Nation’s organizations as well as non-UN humanitarian partners. The members of the IASCare the heads or their designated representatives ofthe UN operational agencies (UNDP, UNICEF, WFP,FAO, WHO, UNFPA, UNHCR). In addition, there isa standing invitation to International Organisation forMigration (IOM), International Committee of the RedCross (ICRC), International Federation of Red Crossand Red Crescent Societies (IFRC), United NationsHigh Commission for Human Rights (UNHCHR),the Representative of the Secretary-General inInternally Displaced Persons (IDPs), InternationalCouncil of Voluntary Agencies (ICVA), SteeringCommittee for Humanitarian Response (SCHR) andWorld Bank. The IASC is chaired by the EmergencyRelief Co-ordinator of the United Nations Office forthe Co-ordination of Humanitarian Affairs(OCHA).The members may be reviewed each year.The IASC has a working group consisting of all themembers. The working group meets every threemonths and can establish Task Forces to assist indeveloping policy or operational guidelines for reliefintervention upon request of the IASC, or asrequired22.The comprehensive guidelines of IASC are to beconducted in three phases: emergency preparedness;during an emergency; and the stabilised phase22. Anapproach can be derived from these guidelines basedon a country’s situation and capacity assessment.Accordingly, it is relevant for organizations to adoptthe following approach consisting of prevention, careand advocacy in the context of AIDS, in connectionwith conflict in Nepal.PreventionPrevention should be primary concern in addressingHIV. A variety of ways could be adopted to preventHIV such as awareness, livelihood activities, food-aid, schooling and availability of condoms.• Awareness program: Such programs provideunderstandings and knowledge of HIV andshould be targeted to vulnerable groups likedisplaced women, waitress girls, economicmigrants etc. This will motivate and help tochange risky behaviour.• Livelihood activities: Various incomegenerating activities that will help sustain lifeparticularly of young girls and women wouldprevent them adopting sexual activities forincome. Vocational training such as cutting,sewing; small cottage industries such asnoodles, blackboard chalk, handicrafts etc;agricultural activities such as vegetableproduction, poultry farming, pig-raising, fruitproduction could be run.• Schooling: Displaced children mainly orphanedand separated children under the age of 18 arevulnerable to sexual violence and exploitation.One of the best ways to bring such children intheir normal and daily routines is continuationon their schooling. Besides normal education,special sessions regarding HIV/AIDS run inschools would help in awareness.• Food Aid: Ensuring food security anddistributing food where necessary to displacedfamilies and communities will lower the dailysurvival burden.• Access to condoms: Condoms are consideredbest weapons to fight against HIV/AIDStransmission. Availability shall be ensured andcorrect ways of use shall be promoted.CareSince early HIV cases are generally asymptomaticproducing a large proportion of carriers of thedisease, early identification of HIV positive andstrong diagnosis facility are important to break thetransmission chain. Voluntary counselling and testingservices will serve this purpose. Identified peoplehaving HIV/AIDS should be cared and incorporatedin a centre so that such people will not bediscriminated and that they will not transmit theinfection to others healthy ones. Various activitiescan be run in centres for daily routine of infectedpeople and to use their labour.
366AdvocacyInternally Displaced Persons (IDPs) in Nepal havebeen neglected by the government and alsounassisted by international humanitarianorganizations. There is not an established nationallegal framework for the protection and assistance ofIDPs. Organizations shall need to advocate andpromote the right of IDPs especially women andchildren, and the disadvantaged and the oppressedgroups. Stigma in Nepal is deeply rooted, whichserve as a barrier to testing, counselling, treatmentand care. Stigma is usually manifested as denial,shame and discrimination.3.2 ImplementationOrganizations interested to tackle the conflict relatedHIV problem will need a committed and complementteam with local offices in the affected areas. Personsshould be identified to handle and take responsibilityon each of identified sectors such as advocacy, care,and prevention under the central command of theDirector of the concerned Organization.Implementation shall proceed as follows:• Conduct capacity and situation analysis of theparticular area; Assess baseline data onprevalence, knowledge, attitudes and practice,and impact of HIV/AIDS, Number of female sexworkers and Number of IDPs.• Set-up monitor and evaluating plan. Developindicators and describe tools.• Conduct awareness campaigns in schools, IDPscamps, restaurants etc on non-discrimination,prevention and transmission of HIV/AIDS• Prepare and develop basic behaviour ChangeCommunication/Information EducationCommunication (BCC/IEC) materials• Schooling of all displaced children withemphasis on orphans and separated children.• Free distribution of condoms to cabinrestaurants; small highway motels• Seek food aid and other humanitarian aid fromgovernment and other donors.• Organise discussion, demonstration etc againststigma of HIV/AIDS, discrimination of theoppressed ones, and the rights of the displacedpeople.• Establish voluntary counselling and testingservices and rehabilitative care for those infectedwith HIV.• Set-up livelihood activities for examples opencottage industries, run vocational training, andinitiate vegetable production.• Identify partners and beneficiaries; shareknowledge; raise funds; work with authoritiesand community people.References1. Durban Decleration (1990). Preventing andcoping with HIV/AIDS in post-conflict societies:Gender Based Lessons from south Africa.2. Smith A (2002). HIV/AIDS andEmergencies:analysis and recommendations forpractice. Overseas Development Institute,London3. Spiegel PB (2004). HIV/AIDS among Conflict-affected and displaced Populations: DispellingMyths and Taking Actions. Disasters 28 (3):322-3394. UNAIDS (2003). HIV/AIDS AND CONFLICT.Fact Sheethttp://www.unaids.org/NetTools/Misc/DocInfo.aspx?LANG=en&href=http://gva-doc-owl/WEBcontent/Documents/pub/Topics/Security/FS_Conflict_en.pdf5. Mock et al (2004). Conflict and HIV: Aframework for risk assessment to people ofconflict-affected settings in Africa. Emergencythemes Epidemiol. 2004;1:66. Gordon et al (2004). A study to Establish theConnections between HIV/AIDS and Conflict.John Snow International (UK)7. Lawday, A. and Webb, D., ‘HIV and Conflict: ADouble Emergency’, Save theChildren,2002http://www.savethechildren.org.uk/temp/scuk/cache/cmsattach/212_hivconflict.pdf8. Machel, G. (1996). Promotion and protection ofthe rights of children: Impact of armed conflicton children.Report of the Expert of the SecretaryGeneral of the United Nations. New York:United Nations. www.unicef.org/graca9. Roberts, B (2004). HIV/AIDS conflict andforced migration. FMO Research guide.http://www.forcedmigration.org/guides/fmo036/fmo036.pdf10. YOUANDAIDS (2005). Nepal at a glance: HIVSituation.http://www.youandaids.org/Asia%20Pacific%20at%20a%20Glance/Nepal/index.asp#scenario11. UN Office for the Co-ordination ofHumanitarian Affairs (2005). Cabin Restaurantspromote sexual exploitation.http://www.irinnews.org/report.asp?ReportID=45900&SelectRegion=Asia&SelectCountry=NEPAL12. Holt et al (2003). Planning STI/HIV preventionsamong Refugees and Mobile populations:Situation Assessment of Sudanese Refugees.Disasters, 2003, 27(1):1-1513. Reliefweb (2004). Nepal:Displaced and ignored.www.reliebweb.int/rw/rwb.nsf/14. Kathmandu Post (05/12/04). Conflict driveschildren towards muglan.
36715. Thieme S, Bhattrai R, Gurung G, Kollmair M,Manandha S, and Müller-Böker, U (2005).Addressing the Needs of Nepalese MigrantWorkers in Nepal and in Delhi, India. MountainResearch and Development, Vol 25 No 2 May2005: 109-11416. Poudel KC, Jimba M, Okumura J, Joshi AB andWakai S(2004). Migrants risky sexualbehaviours in India and at home in far westernNepal. Tropical Medicine and InternationalHealth 9:8, 897-90317. DFID-SDC-GTZ (2003). Conflict and health inNepal: Action for peace-bulding. District healthStrengthening project; Kathmandu,Nepal18. Singh S, Mills E, Honeyman S, Suvedi BK, PantNP (2005).HIV in Nepal: Is the Violent ConflictFuelling the Epidemic? PloS Med 2(8):e21619. UN Office for the Co-ordination ofHumanitarian Affairs (2005). Nepal: Focus onthe plight of rural people living with HIV/AIDS.20. http://www.irinnews.org/report.asp?ReportID=45900&SelectRegion=Asia&SelectCountry=NEPAL21. Subramanian K. S. (2002). Impact of Conflicton HIV/AIDS in South Asia. A Backgroundpaper. http://www.sasnet.lu.se/southasiahiv.pdf22. Country Profile (2003). The HIV/AIDS/STDssituation and the National response in Nepal.National Center for AIDS and STD Control, andUNAIDS. UN House, Kathmndu.23. Inter Agency Standing Committee (IASC),‘Guidelines for HIV Interventions in EmergencySettings’, 2003.http://www.humanitarianinfo.org/iasc/content/products/docs/FinalGuidelines17Nov2003.pdf