seminaronhiv-180201064407.pdf

SEMINAR
ON
HIV AIDS
Presented By: Group B
Prabin Sharma (Roll No 4)
Purnima Timilsina (Roll No 5)
Srijana Tiwari (Roll No 6)
MPH Second Semester, SHAS, PU
Supervised By:
Ms. Bimala Bhatta
Lecturer
Pokhara University

Contents
 Introduction
 Background
 Epidemiological triad
 Epidemiological determinants
 Statement of problem
 Rational of the seminar
 Objectives
 Methodology
 Findings
 Governmental policies and plans
 Challenges
 Conclusion and Recommendations

Background
• HIV stands for Human Immune deficiency
Virus.
• If it is not treated it can leads to acquired
immunodeficiency syndrome (AIDS).
• HIV specially attacks the body immune system
the CD4 cells (T cells)
• Untreated, HIV reduces the number of CD4
cells (T cells) in the body, making the person
more likely to get other infections or infection-
related cancers.

Stages of HIV infection
Stage 1: No AIDS-defining condition
 CD4 count of ≥500 cells/L or CD4 percentage of total lymphocytes of
≥29
Stage 2: No AIDS-defining condition
 CD4 count of 200–499 cells/L or CD4 percentage of total lymphocytes of
14–28.
Stage 3 (AIDS): AIDS-defining condition
 CD4 count <200 cells/L or CD4 percentage of total lymphocytes <14
HIV infection, stage unknown:
 No reported information on AIDS-defining conditions and no information
available on CD4 count or percentage.
AIDS (Acquired immune deficiency syndrome) is the final stage of HIV
infection, which causes damaged to the immune system.

HISTORY
• AIDS was first identified in USA in 1981
when numbers of gay men started to develop
life threatening opportunistic infections like
pneumonia, tuberculosis and cancers.[1].
• In 1981 AIDS was first identified among gay
men in USA.
• In 1983 discovery of a new retrovirus called
Lymphadenopathy-Associated Virus (or LAV)

HISTORY
• In 1983 World Health Organization first
meeting to assess global AIDS situation.
• In 1984 virus was isolated by Gallo and
coworkers from national institute of health in
United States, Human T-cell Lymphotropic
virus III (HTLV-III).
• 1985, the U.S Food and Drug Administration
(FDA) licensed the first commercial blood test,
ELISA, to detect antibodies to the virus.

HISTORY
• In 1985 first International AIDS Conference in Atlanta
Georgia.
• In May 1986, the International Committee on the Taxonomy of
Viruses gave a new name called (human immunodeficiency
virus) instead of HTLV-III/LAV. [2]
• In 1988, the WHO declared 1st December as the first World
AIDS Day.
• Since its identification, HIV/AIDS is devastating disease of
mankind.

Epidemiological Triad of HIV AIDS

Agent
• Human Immunodeficiency
virus(HIV) An RNA virus
• Virus destroy human T4 helper cells a
subset of human T-lymphocytes.
• Virus can pass through blood –brain
barrier and then destroy some brain
cell .this may accounts for certain
neurological and psychomotor
abnormalities.
Source: K. Park 23rd edition

• Type of HIV: HIV-1 and HIV-2
• The virus is easily killed by heat.
• It is readily inactivated by ether,
acetone, ethanol (20 per cent)
and beta-propiolactone (1 :400
dilution), but is relatively
resistant to ionizing radiation and
ultraviolet light.
Agent

• Human are the reservoirs for
the virus
• Cases and Carriers
• Once people infected virus
remain lifelong
• HIV infection can take years to
manifest, symptomless carrier
can infect others
Reservoir of Infection
Source of Infection
• Higher concentration is on
Blood, Semen & CSF.
• Lower concentration is on
Tears, Saliva, Breast milk,
urine, and cervical and
vaginal Secretion.

Age: 20-49yrs
Sex: HIV infects people of any sex
Europe and Australia: 51% homosexual or bisexual man
Africa: Sex ratio is equal
Higher Risk group:
Host Factors
•Prostitutes(heterosexual)
•Male homosexual and bisexual
•Intravenous drug abuser
•Transfusion recipient of blood
and blood product
•Hemophiliacs and clients of
STD.

Environment Factors
• Social norms
• Average rate of sex partner change
• Condom self efficacy
• Local prevalence
• Probability of exposure
• Social and economic determinants

16
Risk Factor of HIV AIDS
• Behaviours and conditions that put individuals
at greater risk of contracting HIV include:
• having unprotected anal or vaginal sex;
• having another sexually transmitted infection
such as syphilis, herpes, chlamydia,
gonorrhoea, and bacterial vaginosis;

17
Risk Factor of HIV AIDS
• sharing contaminated needles, syringes and
other injecting equipment and drug solutions
when injecting drugs;
• receiving unsafe injections, blood transfusions,
tissue transplantation, medical procedures that
involve unsterile cutting or piercing; and
• experiencing accidental needle stick injuries,
including among health workers.

19
Epidemiological determinants

20
Determinants for HIV AIDS in Nepal
• Economic status: Poverty
• Poor education: low literacy regarding HIV and AIDS
• Occupation: CSW, Laborers, migrants, transport workers,
police, militaries, surgeons
• Political system:
Conflicts in country resulting in;
 Movements of women and girls to urban areas
 Economic migration of males from village to urban and urban
to foreign country
 Breakdown of family
 Sexual violence and rape
 Conflict paralyzed national programs
 After conflict solved, people migrate to home place with HIV

21
Determinants for HIV AIDS in Nepal
• Gender inequalities: More in males
• Stigma and discrimination
• Inadequate health care delivery system
• Migration and mobility
• Alcoholism and drug abuse
• Women and child trafficking
• Legal framework: prostitution and legalization issue
• Social tradition: Deuki, Chaupadi, Badi system
• Changing values: early sex
• High population growth and density

Biological factors influencing
HIV transmission
• Disease status of source
patients
• Presence of untreated STIs
in source and person at risk
• Circumcision status
• Gender difference in
susceptibility
• Host genetic difference
Socio-economic factors
influencing HIV transmission
• Social mobility
• Stigma and denial
• People in conflict
• Cultural factors
• Gender
• Poverty
• Drug use and Alcohol
consumption

Global scenario
• Prevalence of HIV increased from 29.8
million in 2001 to 36.9 million in
2014.[3]
• Globally 36.7 million people are living
with HIV in 2016
• World wide 1.8 million people became
newly infected with HIV
Source: UNAIDS Fact sheet 2017

Global scenario
• 54% of adults and 43% of children living with
HIV are currently receiving lifelong
antiretroviral therapy (ART).
• World wide 1 million people died from AIDS
related illness in 2016.
• Global ART coverage for pregnant and
breastfeeding women living with HIV is high
at 76% .
Source: UNAIDS Fact sheet 2017

• The WHO African Region is the most affected
region, with 25.6 million people living with
HIV in 2016. The African region also accounts
for almost two thirds of the global total of new
HIV infections.
• Sub-Saharan Africa remains most severely
affected, with nearly 1 in every 25 adults
(4.2%) living with HIV and accounting for
nearly two-thirds of the people living with HIV
worldwide
Source:WHO Report 2016
Global scenario

Estimated number of people living with HIV
globally(2016)
USAID 2017

National Scenario
• In Nepal, first case of HIV/AIDS was
diagnosed in 1988
• Prevalence of HIV decline from 40,723 in
2013 to 39,397 in 2015
• 1331 people were newly infected with
HIV and there were 2263 AIDS-related
deaths in 2015.
Source: Annual Report 2072/73

National Scenario
• Number of estimated deaths is projected
to decline to 1,266 in 2020.
• 73% of total estimated infections(30,074)
are among 15-49 year old.
• Prevalence of HIV among 15-49 year old
was 0.2% in 2015.
Source: Annual Report 2072/73

Distribution of reported HIV cases by
developmental Region
Source: NCASC, July 2017

Estimated HIV infection by age group
Source: NCASC, July 2017
Male Female

Rational of the seminar
• Recognized as an emerging disease only in the early 1980s, AIDS has
rapidly established itself throughout the world, and is likely to endure and
persist well in 21st century.
• AIDS has evolved from a mysterious illness to a global pandemic which
has infected tens of millions people.
• Promising development have been seen in recent years in global efforts to
address the AIDS epidemic, including increased access to effective
treatment and prevention programs.

• However, the number of people living with HIV continues to
grow as does the number of deaths due to AIDS.
• Of particular concern are trends affecting Eastern Europe and
Central ASIA, where the numbers of people acquiring HIV
infection and dying from HIV related causes continue to
increase.
• Among the special features of HIV infection are that once
infected, it is probably that a person will be infected for life.

• Study have shown that considerable knowledge gap about
the issue, and the economic burden exerted by HIV/AIDS
are big enough to push the affected households into
poverty.
• Study have reported that there was a separation of PLHA
from communities and families, loss of employment and
restrictions on movement and activities in communities.

Objectives
General Objective
• To study epidemiology and overview of current policies,
strategies and programs for prevention and control of HIV
AIDS
Specific Objectives
• To explore epidemiological distribution and determinants
of HIV AIDS.
• To review the milestone of HIV AIDS control in Nepal.
• To evaluate the current situation of HIV AIDS control
program.
• To discuss on policy and strategies on HIV AIDS.
• To explore prevention and control methods of HIV AIDS

Methodology
• Search Engine: Google Scholar, Endnote, Books
• Study Duration: 4th Dec to 10th December
Endnote
• Keywords used: HIV, AIDS, Nepal

HIV
Human Immunodeficiency Virus
• H= Infects only Human beings
Transmitted among Human
Preventable by Human
• I= Immunodeficiency
virus weakens the Immune system and
increases the risk of infection
• V= Virus that attacks the body
Lives and reproduce in body cells

AIDS
Acquired Immune Deficiency Syndrome
• A= Acquired, not inherited
• I= Weakens the Immune system
• D= Creates a Deficiency of CD4 cells in the
immune system
• S= Syndrome, or a group of illness taking
place at the same time

HIV is found in body fluids
• Semen
• Breast milk
• Blood
• Vaginal fluids
Mode of Transmission
• Sexual contact
• Parenteral
• Perinatal

Coughing, Sneezing Touching Hugging
Sharing water, Food Public Baths/Pool Handshakes
Sharing Cup/Glasses or other Utensils

• Window Period:
6 weeks to 3 months
• Incubation Period:
uncertain(from few month to 10yrs from HIV
infection to development of AIDS)

Clinical Features
The clinical presentation of HIV and AIDS has been
divided into four phase of infection:
• Primary infection
• Asymptomatic Carrier Stage
• AIDS related complex
• Progression to AIDS

Primary infection
• The majority of people infected by HIV develop flu-
like illness few weeks after the virus enters the body.
• Known as initial or acute HIV infection
• May last for a few weeks
• Many people may not experience any symptom
• Amount of virus in blood stream- High
• HIV infection spreads more efficiently

• Possible symptom include: Fever, myalgia, rash,
headache, sore throat, mouth or genital ulcers,
swollen lymph glands, mainly on the neck, joint pain,
night sweats and diarrhoea.
• HIV antibodies takes 2-12 weeks to appear in blood
• Period before antibody appear- Window Period
during which antibody test will be negative.
Primary infection

Asymptomatic Carrier Stage
• Known as clinical latent infection
• Infected people have antibodies, are infectious but
there are no specific sign and symptoms.
• Persistent swelling of lymph nodes occurs in some
people
• Virus remains as free virus in body and in infected
white blood cells
• Last for 8-10 years or longer

AIDS related complex
• Mild infection or chronic symptoms due to viral
multiplication and damage to immune system.
• Transition from asymptomatic HIV infection to
symptomatic HIV infection
• Symptoms: recurring fever, unexplained weight loss,
swollen lymph glands and diarrhoea lasting longer
than a month, fatigue, cough and shortness of breath.

Progression to AIDS
• End stage of HIV infection is AIDS
• Severely damaged immune system, making person
susceptible to number of opportunistic infection and
cancers.
• Tuberculosis and Kaposi sarcoma are the earliest to
occur

Progression to AIDS
• Clinical presentation: Soaking nights sweats, shaking chills or
fever higher than 100 degree F for several weeks, cough and
shortness of breathe, chronic diarrhoea, persistent white spots
or unsual lesion on tongue or mouth, headache, unexplained
fatigue, blurred and distorted vision, severe weight loss, skin
rashes or bumps.
• Chronic diarrhoea and severe weight loss leads to wasting
syndrome and known as slim disease.

Complication
• HIV infection weakens the immune system, thus making the
individual highly susceptible to all sorts of infection and certain
types of cancers.
• Most common infection associated with HIV AIDS include: TB,
Cytomegalo virus, oropharyngeal candidiasis, cryptococcal
meningitis, toxoplasmosis, cryptosporidiosis, Pneumocystis
carnii Pneumonia, Herpes zoster, Kaposi’s sarcoma and
lymphomas.
• Others:
wasting syndrome(loss of at least 10% body weight), HIV
associated nephropathy and neurological complications such as
confusion, depression, anxiety, trouble walking and dementia
complex leading to behavioral changes and diminished mental
functioning

Prevention, Control and Treatment

Prevention
Primordial
• Discouraging people to adopt harmful behavior
Primary: Primary HIV prevention refers to activity focused on preventing
uninfected people becoming infected.
• Health education:
– avoiding indiscriminate sex
– Using condoms
– Avoid use of shared razor & toothbrush
– Avoid sharing of needles and syringe
– High risk group should avoid pregnancy
– Widely availability of IEC/BCC material and involvement of mass
media in P3CE activities.
• Peer group education:
• School Curriculum:

• Most at Risk population
– Prostitutes(heterosexual)
– Male homosexual and bisexual
– Intravenous drug abuser
– Transfusion recipient of blood and blood product
– Hemophiliacs and clients of STD.
• Behavioral modification : Blood transfusion , needle sharing,
multiple sexual partner, mother to child transmission
• Specific protection
– Prevent cross infection from infected to non –infected patient
– Safe guard the health care personnel who are at risk of getting
infected
– Avoid infection getting into the society through hospital wastes.
Prevention

Condom promotion:
– Use a new condom with each sex act (i.e., oral, vaginal, and anal).
– Carefully handle the condom to avoid damaging it with fingernails,
teeth, or other sharp objects.
– Put the condom on after the penis is erect and before any genital, oral,
or anal contact with the partner.
– Use only water-based lubricants (e.g., K-Y Jelly, Astroglide, AquaLube,
and glycerin) with latex condoms. Oil-based lubricants (e.g., petroleum
jelly, shortening, mineral oil, massage oils, body lotions, and cooking
oil) can weaken latex and should not be used; however, oil-based
lubricants can generally be used with synthetic condoms.
– Ensure adequate lubrication during vaginal and anal sex, which might
require the use of exogenous water-based lubricants.
– To prevent the condom from slipping off, hold the condom firmly
against the base of the penis during withdrawal, and withdraw while the
penis is still erect.
Prevention

• Secondary: Secondary HIV prevention aimed at enabling people with HIV
to stay well (i.e. testing to allow people to know their status: welfare rights
advice: lifestyle behavior: anti discriminatory lobbying)
• VCT
• Screening test: western blot, elisa
• Diagnostic test
Prevention

Tertiary:
Tertiary HIV prevention aims to minimize the effects of ill health
experienced by someone who is symptomatic with HIV disease (i.e. .the
prophylactic use of drugs and complementary therapies)
Rehabilitation:
 Economic:
• Social security fund
• Employment creation
 Social:
• Convey acceptance, warmth, respect, empathy and confidentiality
• Increased social interaction
• Make a positive contribution they can leave behind when they die
• Policy and programme development
Prevention

 Vocational :
• Professional education and practice development:
HIV patient experienced and have the appropriate skills and knowledge
regarding HIV/AIDS and ART matters, factual knowledge concerning the
disease, its route of transmission, as well as ART so they can counsel
persons infected and affected by HIV/AIDS.
Prevention

ABC approach to prevent HIV/AIDS:
A= Abstain
B= Be faithful
C= use condom
Prevention

Diagnosis

Laboratory Diagnosis
• Screening Test
1. ELISA (sensitive test)
2. Western Blot
(Confirmatory test)
• Virus Isolation
Source: K. Park

Laboratory Diagnosis: ELISA and Western blot
• ELISA: Enzyme Linked Immunosorbent Assay
• Detects presence of HIV antibodies in a blood
• Positive ELISA test is followed by western blot
• ELISA test is rapid test while WB takes longer time
• Viral isolation can be also performed but its
applicability is limited due to complexity of technique

Antiretroviral treatment
• The drugs do not kill or cure the virus. However,
when taken in combination they can prevent the
growth of the virus.
• When the virus is slowed down, so is HIV disease.
• Antiretroviral drugs are referred to as ARV.
Combination ARV therapy (cART) is referred to as
highly active ART(HAART)
• ARV chemotherapy have proved to be useful in
prolonging the life of severely ill patients.
• ARV suppress the HIV replication.
Source: K. Park

• Standard antiretroviral therapy (ART) consists of the
combination of antiretroviral (ARV) drugs to
maximally suppress the HIV virus and stop the
progression of HIV disease.
• The World Health Organisation (WHO) has
recommended a combination of antiretroviral drugs
for people starting HIV treatment: TDF (tenofovir)
either 3TC (lamivudine) or FTC (emtricitabine) and
EFV (efavirenz)
Source: K. Park

• There are currently five different classes of HIV
drugs based on their mode of action.
1. Non-nucleoside reverse transcriptase inhibitors
(NNRTIs):
• These drug blocks the enzyme, reverse transcriptase,
and prevent HIV from making copies of its own
DNA.
• Example: efavirenz(sustiva), etravirine(intelence)
and nevirapine(viramune)

2. Nucleoside/Nucleotide reverse transcriptase
inhibitors (NRTIs):
• These drug acts as a faulty bulding blocks in
production of viral DNA and thus blocks HIV’s
ability to use reverse transcriptase , an enzyme
required for viral replication.
• Example: abacavir(Ziagen) and combination drug
emtricitabine and tenofovir (truvada), lamivudine
and zidovudine.

3. Protease Inhibitors (PI):
• Its another protein that HIV needs to replicate and
protease inhibitors works by blocking this enzyme
• Example: atazanvir(reyataz), darunavir(prezista),
fosamprenavir (lexiva) and ritonavir (norvir).
4. Entry or Fusion Inhibitors:
• These drugs block HIV’s entry into CD4 cells by
targeting the receptors sites on either HIV or CD4
cells.
• Example: enfuvirtide (fuzeon) and maraviroc
(selzentry)

5. Integrase Inhibitors:
• Integrase is the enzyme responsible for reverse
transcriptase, whereby the viral genetic material is
integrated into the genetic material of the host cells.
• Integrase inhibitors block this enzyme and prevent
the virus from adding its DNA into DNA of hosts
CD4 cells.
• Example: raltegravir (isentress)

Specific prophylaxis
• Specific prophylaxis treat manifestation of AIDS
• Primary prophylaxis against P.carinii pneumonia should be offered to
patients with CD4 count below 200 cell/ul.
• Rifabutin is for person with less then 200CD4 cell/ul.
• 300 isoniazid daily for 9 month to 1 yrs against M. tuberculosis
• Kaposi’s sarcoma might be treated with Interferon, chemotherapy or
radiation
• Cytomegalovirus retinitis can be controlled by ganciclovir
• Herpes simplex infection and herpes zoster can be treated with acyclovir or
foscamet.
Source: K. Park

Primary Health Care
AIDS control program is essential to integrate with all
aspects of primary health care including
• Mother and child health
• Family planning and education
Source: K. Park

Governmental policies and plans

Year Activity
1988 Launched the first national AIDS Prevention and control Program
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 for HIV/AIDS Nepal
2002-2006 National HIV/AIDS strategic plan
2003-2007 National HIV/AIDS Operational plan
2006-2011 National HIV/AIDS strategic plan
2008-2011 National HIV/Aids Action plan
2007 National HIV/AIDS and STD control board established
2008 National HIV/AIDS Action plan
2010 New National Policy on HIV/AIDS
2011-2016 National HIV/AIDS Strategic Plan
2016-2021 New National HIV/AIDS Strategic Plan

Nepal strategy for
HIV/AIDS control
• National AIDS council:
Prime minister- chairperson
• National AIDS coordinator
committee: Health minister-
chairperson
• National centre for AIDS
and STD control: Director
Key guiding policy
• High priority for program
• Multi-sectoral approach
• Decentralization
• PPP
• Integration with other
program
• Promotion of safe sexual
behavior
• No discrimination of HIV
patients
• Confidentiality of blood
report

Strategies for priority areas
Vulnerable groups:
• Increase awareness
• Promotion of 100% condom use
Young people:
• Healthy behavior and safe style
• Safe sex and condom use
• IEC about HIV AIDS
• Sex education and VCT
• Focus on school curriculum regarding HIV AIDS

Treatment, care and support:
• Use of mass media to remove misconception
• Remove stigma
• VCT for CSW, IV drug users and high risk groups
• Establish treatment centers
• Blood safety and rational use for patients
• Care and social support for patients

Epidemiology, Surveillance and Research:
• Sentinel surveillance and research
Management and implementation of and
expanded response:
• Leadership at highest level
• Strengthening of implementation capacity
• Development of district strategies
• Public private partnership

National HIV AIDS Control Programme
• Nepal began its policy response to the HIV epidemic
through its first National Policy on Acquired
Immunity Deficiency Syndrome (AIDS) and Sexually
Transmitted Disease (STD) Control (1995).
• Considering the dynamic nature of the epidemic the
policy was revised in 2011 as the National Policy on
Human Immunodeficiency Virus (HIV) and Sexually
Transmitted Infections (2011).
• Based on the latest policy, the country implemented
its fourth National HIV/AIDS Strategy (2011-2016).

• A new National HIV Strategic Plan (2016-2021) was
recently launched with the ambitious 90-90-90 goal,
that by 2020.
• 90 percent of all people living with HIV know their
HIV status,
• 90 percent of all people with diagnosed HIV infection
receive sustained antiretroviral therapy and
• 90 percent of all people receiving antiretroviral
therapy have viral suppression.

Policy environment and progress in national
HIV response
The National Policy on HIV and STI :
• The National Policy on HIV and STI (2011) accords
HIV and AIDS a high priority in national
development.
• It calls for a multi-sectoral, decentralized and
inclusive response based on the ‘three ones’ of
i) one agreed HIV/AIDS Action Framework that
provides the basis for coordinating the work of all
partners,
ii) one national AIDS coordinating authority and
iii) one agreed country level M&E system.

The Nepal Health Sector Programme :
• NHSP-2 (2010-2015) embraced a plan to halt or
reverse HIV prevalence, and committed to scaling up
HIV-related interventions under the essential health
care package within the broader framework of
communicable diseases.
• It also recognized the need to expand sexual and
reproductive health (SRH) services and integrate HIV
into them.
HIV response

National HIV Strategic Plan:
• The National HIV Strategic Plan (2016-2021), aims
to meet the global 90-90-90 goal by 2020.
• The plan is focused on building one consolidated,
unified, rightsbased and decentralized HIV
programme with services that are integrated into
general health services.
• It builds on lessons learned from implementing the
National AIDS Strategy (2011–2016), its mid-term
review and the Nepal HIV Investment Plan (2014–
2016); and applies recommendations from the AIDS
Epidemic Model exercise.
HIV response

National Health Sector Strategy (2015-2020):
• The National Centre for AIDS and STD Control
(NCASC) is accountable for implementing the
National HIV Strategic Plan through public health
services.
• Its implementation takes place in coordination with
other public entities and the private sector, including
services provided by civil society and other non-
government networks and organizations.
HIV response

National Health Sector Strategy (2015-2020):
• Because financing the HIV response in Nepal relies
heavily on external funding, which is rapidly declining, it
is imperative that public-private partnerships are
established and maintained, and that wise, evidence
informed investment choices are made.
• The commitment by Nepal to the global UNAIDS
Strategy (2016-2021) and the SDGs include commitments
to fast-track the HIV response to achieve the 90-90-90
targets by 2020 and to end the AIDS epidemic as a public
health threat by 2030.
HIV response

Other sectoral plan and policies:
• A number of sectoral plans and strategies such as
Education for All, the School Sector Reform Plan (2009-
2015) and National Youth Policy have envisaged
complementary roles in the national HIV response.
• The National Policy on HIV in the Workplace (2007) and
the National Drug Control Policy (2006) reinforced the
national HIV response.
• The enactment of the Gender Equality Act (2006) and the
Human Trafficking and Transportation (Control) Act
(2007) helped bring about an inclusive environment to
guide the national HIV response.
HIV response

Guidelines and documents:
• The Consolidated Guidelines on Treating and
Preventing HIV in Nepal (2014),
• National Guidelines on Monitoring and Evaluation of
HIV Response in Nepal (2012), and
• National Guidelines of Case Management of Sexually
Transmitted Infections (STIs) (2014) guide the
response.
HIV response

Policy related activities in 2072/073
• The mid-term review of the National HIV/AIDS Strategy
(2011–2016) and the production of the Nepal HIV Investment
Plan (NHIP, 2014-2016) have helped ensure that the national
HIV response is abreast with the latest scientific advances and
is fine-tuned to the dynamics of HIV in the country.
• The midterm review of the strategy fed into the production of
the NHIP.
• Following the recommendation of the review for more efforts
to eliminate mother to child transmission, the government
pledged to provide lifelong antiretroviral treatment (ART) to
all pregnant and breastfeeding mothers with HIV and
prophylactic treatment for their infants.

 Nepal HIV Investment Plan 2014–2016:
• Built on the principles of UNAIDS’ Investment Framework
and the National Strategy (2011–2016), the Nepal HIV
Investment Plan (2014–2016) makes a compelling case for
strategic investments in Nepal’s HIV response.
• Its three year operational plan and budget guided the
implementation of the national strategy.
• This NHIP aims to ensure that available resources are
concurrent with Nepal’s HIV programme objectives and goals,
and contribute to the effectiveness and efficiency of the entire
national HIV response.

 Other guidelines :
• National guidelines on a monitoring system for HIV drug
resistance (HDR) and early warning indicators were prepared
and put into operation in 2071/72.
• A single and comprehensive document of consolidated
guidelines, encompassing treatment care and support, HIV
testing and counselling (HTC) and PMTCT, is being prepared
under NCASC with support from WHO, UNICEF and the
Saath-Saath Project.

HIV testing services and STI management
• First HIV testing center opened in 1995 to provide voluntary
client-initiated testing and counselling (CITC)
• Later on its approach is widened to include provider-initiated
testing and counselling (PITC)
• Both approaches are voluntary, where the client gives verbal
consent for HIV testing.
• Facility based services are provided by the government and
NGOs.
• Provider-initiated testing and counselling (PITC) takes place in
STI clinics, antenatal clinics, birthing centres and maternity
units, nutrition clinics and alongside postpartum, family
planning and TB services.

Source: National HIV Testing and Treatment Guidelines 2017

 Strategies and activities:
HIV testing services :
• The National HIV Strategic Plan envisages the rapid scaling up of
testing by expanding community-led services in targeted locations
with strong referral links to higher level treatment, care and support.
• The national strategy calls for the public health system gradually
providing HIV testing services.
• The government is promoting HIV testing among key populations
through targeted communications and improved links between
community outreach and testing services.
• Provider-initiated testing andvcounselling (PITC) takes place in STI
clinics, antenatal clinics, birthing centres and maternity
units,vnutrition clinics and alongside postpartum, family planning
and TB services.

 Strategies and activities:
Detection and management of STIs
• The standardization of quality STI diagnosis and treatment to
health post level as a part of primary health care services is a
key strategy of the national response.
• The strategy also foresees the standardization of the syndromic
approach with referral for etiological treatment when needed.
• The strengthening of documented linkages (follow-up
mechanisms) between BCC services and HIV testing and
counselling, including strengthening links between HIV testing
and STI services, is a key strategy for Nepal’s concentrated
epidemic.

Prevention of Mother to Child Transmission
• PMTCT services started in Nepal from 2005
• Prevention of mother-to-child transmission (PMTCT)
programmes provide antiretroviral treatment (ART) to HIV-
positive pregnant women to stop their infants from acquiring
the virus.
• Primary prevention of HIV transmission,
• Preventing unintended pregnancies among women living with
HIV,
• Preventing HIV transmission from women living with HIV to
their children, and
• Providing treatment, care and support for women living with
HIV and their children and families

 Services provided to pregnant women.
 HIV testing and counselling during ANC, labour and delivery
and postpartum
 Antiretroviral drugs to mothers infected with HIV infection
 Safer delivery practices
 Infant feeding information, counselling and support
 Early infant diagnosis (EID) of HIV exposed children at 6
weeks
 Referrals to comprehensive treatment, care and social support
for mothers and families with HIV infection.

Service statistics on PMTCT in Nepal, 2070/71 -2072/73

Community-Led HIV Testing Services (CL-HTS)
• The NHSP 2016–2021 has endorsed, community-led
HIV testing (CL-HTS) as part of the CBT following
the ‘test for triage' strategy for screening and referral
approach.
• Organizing and managing of community testing sites,
conducting of pre- and post-test services, and rapid
diagnostic testing are performed by trained members
of the KP.
Source:National HIV Testing and Treatment Guidelines 2017

Who to test When to test Where to test
People with signs or
symptoms of HIV
infection, including TB,
Hepatitis patients,
patients
Integrate in healthcare
encounter– provider-
initiated HIV testing and
counselling in health
facilities, including
through community in-
reach
HTS centres, STI clinics,
TB clinics, hospitals,
Primary Health Care
(PHC), health posts,
other clinics, stand-alone
clinics, OST sites and
community settings
Partners of people with
HIV
As soon as possible after
partner diagnosis. For the
negative person in
Serodiscordant couples,
offer re-testing every 6–
12 months
HTS centres, TB clinics,
STI clinics, hospitals,
PHC, health posts,
community led HTS
Families of index cases As soon as possible after
the family member is
diagnosed
member is diagnosed
HTS centres, community-
led, including home-
based, hospitals, PHC,
health posts testing
services

Who to test When to test Where to test
KP: people who inject
drugs, gay men and
other men who have sex
with men, transgender
people and sex workers
Every 3 months HTS centres, STI clinics,
community led services
for KP and harm-
reduction services,
hospitals, PHC, health
posts
Pregnant women At the first antenatal
care visit–provider
initiated HIV testing and
counselling
ANC settings, hospitals,
PHC, health posts
Migrant workers On their return to place
of origin and before
departure to destination.
If any signs and
symptoms of HIV
infection
HTS centres, STI clinics,
community-led services
for KP

HIV treatment, care and support services
• To reduce mortality among HIV-infected patients, in 2004
the government started providing free ARV drugs in
public hospitals, followed by the production of national
guidelines on ARV treatment.
• Since then, a wide range of activities have been carried
out to treat, care and support PLHIV.
• ART sites have been set up across the country.
• The National Consolidated Guidelines for Treating and
Preventing HIV in Nepal (2014) supports the programme.

• Diagnostic and treatment-related infrastructures
including CD4 and viral load machines installed in
different parts of the country for the management of
ART.
• Health workers have been trained to treat, care and
support PLHIV in parallel with the preparation and
updating of training guidelines.
• PLHIV have been empowered to become involved in
treatment, care and support.

Progress and achievements:
• Nepal had 65 ART sites across 59 districts at the end of
2072/73. There has been a gradual increase in the number of
people enrolling on ART and receiving ARVs.
• The total number of PLHIV who were receiving ART by the
end of 2072/2073 had reached 12,446. By the end of 2015, of
the 11,922 people on ART, 9,979 had been retained on
treatment for 12 months.
• Among the total PLHIV on ART tested (5,860) almost 90
percent (5,249) were viral load suppressed.

Progress and achievements:
• Of all patients registered on ART, 86.6 percent were still
actively on ART after 12 months while 79 percent were still
actively on ART after 24 months of treatment. And of all
PLHIV currently on ART, 92 percent are adults and 8 percent
are children while 51.8 percent are males and 47.9 percent
females.
• Fifteen percent of those ever registered on ART have died
while 10 percent have been lost to follow-up and 75 percent
are alive on treatment.

ART profile in 2070/71 to 2072/73:
Indicators 2070/71 2071/72 2072/73
People living with HIV
ever enrolled on ART
(cumulative)
12,898 14,745 16,499
People with advanced HIV
infection receiving ARVs
(cumulative)
9,818 11,089 12,446
People lost to follow up
(cumulative)
1,055 1,216 1,612
People stopped treatment 27 30 31
Total deaths (cumulative) 1,463 1,834 2,410
Source: NCASC

National HIV Strategic Plan
2016-2021

2016-2021
• The National HIV Strategic Plan has been prepared
through a wide range of consultations, including the
Nepali Government, civil society networks,
international partners and service providers, under the
leadership of the National Centre for AIDS and STI
Control.
• The National HIV Strategic Plan includes
recommendations from these consultations as
strategic directions.
2016-2021

2016-2021
Vision:
ending the AIDS epidemic as a public health threat in Nepal
by 2030
Targets and indicators for Fast-Tracking the response by
2021
- Identify, recommend and test 90% of key populations.
- Treat 90% of people diagnosed with HIV.
- Retain 90% of people diagnosed with HIV on antiretroviral
therapy.
- Eliminate vertical transmission of HIV and keep mothers
alive and well.
- Eliminate congenital syphilis.
- Reduce 75% of new HIV infections.
2016-2021

2016-2021
Strategies:
• Focus on reaching key populations through outreach and, by
communities of key populations, through in-reach.
• Offer HIV “test and treat” services, regardless of CD4 count.
• Retain people living with HIV in treatment, resulting in
undetectable viral load.
• Fast-Track prioritized investments with a scope, scale,
intensity, quality, innovation and speed to have the biggest
impact.
• Enhance critical programme and critical social enablers.
• Establish functional public-private partnerships to bridge the
prevention.treatment continuum through task-sharing.
• Focus on innovative, well-coordinated and integrated services
towards primary HIV prevention for and with key populations.
2016-2021

Indicators and targets to be achieved by 2021
Source: National HIV Strategic Plan 2016-2021

Source: National HIV Strategic Plan 2016-2021

2016-2021
Guiding principles:
• Universal equitable access to services for HIV
prevention, treatment, care and support,
• National solidarity and shared responsibility,
• Fast-Tracking towards ending the AIDS epidemic as a
public health threat,
• Integration of HIV within systems for health,
• Innovation,
• Evidence-informed planning and programming,
• Decentralized, multisector and interdisciplinary
engagement,

2016-2021
Guiding principles:
• People-centred inclusive approaches,
• Advancing human rights,
• Gender justice,
• Zero tolerance for prejudice and discrimination
related to HIV and key populations,
• Prevention and treatment continuum using the
.identify, reach, recommend, test,
• treat and retain. approach,
• Meaningful involvement of affected communities,
• Public-private partnerships and task-sharing, and
• Country stewardship.
2016-2021

Government of Nepal
Ministry Of Health
National Centre for AIDS and STD control

Vision:
Ending the AIDS epidemic as a public health
threat in Nepal by 2030
Goals and Targets:
• Identify, recommend and test 90% of key
populations.
• Treat 90% of people diagnosed with HIV.
• Retain 90% of people diagnosed with HIV on
antiretroviral therapy.
• Eliminate vertical transmission of HIV and keep
mothers alive and well.
• Eliminate congenital syphilis.
• Reduce 75% of new HIV infections.

Strategies
• Focus on reaching key populations through outreach and, by
communities of key populations, through in-reach
• Offer HIV “test and treat” services, regardless of CD4 count.
• Retain people living with HIV in treatment, resulting in
undetectable viral load.
• Fast-Track prioritized investments with a scope, scale,
intensity, quality, innovation and speed to have the biggest
impact.

Strategies
• Enhance critical programme and critical social enablers.
• Establish functional public-private partnerships to
bridge the prevention-treatment continuum through
task-sharing.
• Focus on innovative, well-coordinated and integrated
services towards primary HIV prevention for and with
key populations.

World AIDS Day
In 1988, the WHO declared 1st December as the
first World AIDS Day.

Some organization working in Nepal
• National Association of People Living with
HIV/AIDS in Nepal (NAP+N)
• National NGOs Network Group Against AIDS, Nepal
(NANGAN)
• National Federation of Women Living with HIV and
AIDS (NFWLHA)
• Friendship Association for Community Education ,
Nepal (FACE Nepal)
• Community Action Center- Nepal (CAC-Nepal)
• Samjhauta Nepal
• Maiti Nepal

HIV Surveillance in Nepal
Nepal has been monitoring HIV and STI epidemic by
collecting routine data from the following sources:
Case Reporting of HIV and STI
• Routine case reporting of HIV and STI is done from
HIV testing and counseling and PMTCT sites as well
as other service sites.
• The routine reporting of HIV and STI from these sites
is integrated in HMIS since 2014.
Source: NCASC, 2017

Integrated Biological and Behavioral Surveillance
• Nepal has been conducting HIV and STI surveillance
particularly among key populations, namely: PWID,
FSW and their clients, MSM/TG, and male labor
migrants for more than a decade mainly to track
changes in HIV and STI prevalence along with
behavioral components such as condom use.
• Hepatitis-B and C screening among PWID has been
started in the IBBS surveys from 2015.
Source: NCASC, 2017

Monitoring of HIV Drug Resistance
• Preparations for setting up a system for monitoring of HIV drug
resistance for example, monitoring of early warning indicators is
underway.
• In this regards, guidelines on monitoring for HIV Drug Resistance
Early Warning Indicators has been prepared in November 2013.
• First HIV drug resistance survey has been completed in 2017 and
finding of study is yet to be disseminated.
• For the survey, the survey blood samples were collected for
Antiretroviral Drug Resistance surveillance (ADR) and pretreatment
drug resistance (PDR) surveillance from 21 ART sites of Nepal.
• The aim of the survey was to assess the prevalence and patterns of both
acquired as well as pretreatment drug resistance in the country.
Source: NCASC, 2017

Size estimation of key populations
• The size estimation of key population (FSW, PWID,
MSM/TG) in districts was conducted in 2010. The second
round of size estimation was done in 2016
HIV Infection Estimations and Projections
• These are being done annually in Nepal based on available
prevalence and population size data among population groups
as well as the updated program coverage of key interventions
such as ART, PMTCT and TB-HIV.
• Nepal contributes to the regional and global estimates of
epidemic update through UNAIDS/WHO calendar. Nepal
contributes every year to the country estimates for Global
Epidemic Update.
Source: NCASC, 2017

HIV surveillance
• Results are regularly disseminated to policy makers, program
managers, development partners and other relevant stakeholders to
ensure public health actions.
Sentinel surveillance
• Sentinel Surveillance among key populations at higher risk, ANC
attendees and STI patients are planned and will be started in the all
regional, zonal and central level hospitals across regions.
• NCASC is taking the lead in HIV surveillance activities in Nepal, in
technical collaboration with WHO, UNAIDS and USAID/Saath-
Saath Project including the engagement of communities and people
living with HIV.
Source: NCASC, 2017

Articles
• In 2014 matched case-control study was conducted to identify the social
and behavioural factors for HIV infection among the wives of labour
migrants in Nepal.
• 112 wives of labour migrants diagnosed with HIV (cases) and 112 wives of
labour migrants testing negative for HIV (controls) were interviewed.
• Literacy status was the only one woman-related social factor associated
with HIV infection.
• Literacy status, age when going abroad for the first time and country of
migration were the husband-related social factors and alcohol consumption,
living alone abroad and having an unpaid partner abroad were the husband-
related behavioral factors associated with HIV infection in the wives.
• Study recommended prevention efforts must incorporate behaviour change
approaches targeting specifically to labour migrants and also to their
wives. [6]

Articles
• A descriptive study was carried out in Sukraraj Tropical and
Infectious Disease Control Hospital, Teku and Bir Hospital
in 2071 to assess Problems Faced by Antiretroviral (ARV)
Drug Users in Kathmandu valley.
• Overall problems faced by antiretroviral drug users include
side-effects of drugs (65.9%), long waiting time (24.4%),
unsatisfactory service (4.9%), geographical (68.3%) and
financial barrier (25.6%), etc. Few were turned off from
social/religious (70.7%) and recreational activities (51.2%).
Absence of disclosure (14.6%), lack of spousal support
(10.9%), humiliation (34.1%), etc. were also present.
• ART is a long term process and to achieve it rationally, a
user has to cope with lots of problems, associated not only
with physical health but also with outcomes of psychosocial
issue.[7]
Articles

Articles
• A review study was conducted to find the existing knowledge gap
about the economic burden of HIV/AIDS at the household level in
Nepal, the extent of economic burden exerted by the disease and to
provide policy recommendations.
• Study concluded that there was a considerable knowledge gap about
the issue, and the economic burden exerted by HIV/AIDS was big
enough to push the affected households into poverty.
• It was suggested that more studies need to be conducted to fill the
knowledge gap.
• Similarly, Government of Nepal and other organisations working in
the field of HIV/AIDS need to provide economic supports (e.g.-
support for travel costs) to the HIV positive people and need to
increase the awareness level among general population for reducing
stigma and discrimination, and reducing economic burden on
them.[8]
Articles

Articles
• A study by was done by Family Health
International in 2004 regarding Community
Attitudes and the Forms and Consequences for
Person Living with HIV/AIDS.
• Study reported that there was a separation of
PLHA from communities and families, loss of
employment and restrictions on movement and
activities in communities.
• Moreover, it was reported that HIV positive
women were discriminated greatly compared to
men and more often faced permanent loss of
family support. [9]
Articles

Articles
• A qualitative study was carried out in 2013 in far west of Nepal to
explore sexual behavior and condom use among seasonal Dalit
migrant laborers to India from Far West, Nepal.
• Study revealed that poor socio-economic status, caste-related
discrimination, and lack of employment opportunities push large
groups of young Dalits to migrate to India for employment, where
they engage in sex with female sex workers (FSWs).
• The participants described unmarried status, peer influence, alcohol
use, low-priced sex with FSWs and unwillingness to use condoms as
common factors of their migration experience.
• Lack of awareness on HIV/AIDS was common among study
participants.
• Awareness of HIV/AIDS and faithful, monogamous partnerships are
reported as factors influencing safer sexual behavior. [10]
Articles

• Poverty
• Low education
• Gender inequalities
• Stigma and discrimination
• Inadequate health care delivery
• Insurgency and insecurity
• Migration (Push and Pull factors)
• Alcoholism and drug abuse
• Women trafficking and child abuse
• Social traditions
Pitfalls

Issues:
• The large data gaps in HIV reporting, especially from regional,
sub-regional, zonal and district hospitals that are yet to be
covered by electronic HMIS.
• All NGO testing sites are not covered under the HMIS
database system.
• Low HIV testing among key populations is a longstanding
challenge. The problem is most prominent amongst returning
labour migrants.
• Inadequate staff, especially trained HIV counsellors in
government sites, especially PMTCT sites.
• Problem in the expansion of HIV testing sites.
HIV testing and STI management

Recommendation:
• Strengthen coordination between DPHOs and hospitals.
• Strengthen coordination between DPHOs, the HMIS and
NGOs. Enlist all working NGOs in the system to give total test
numbers.
• Rollout the community-led HIV testing and treatment
competence (CTTC) approach with strong monitoring. Provide
testing facilities at transit points and migrant destinations.
• Ensure adequate trained HIV counsellors in sustainable way at
all relevant service sites.
• Scale-up testing sites to increase accessibility and initiate
community-based testing.

Issues:
• Inadequate laboratory personnel at PMTCT sites
• The tracking of HIV-positive mothers and exposed
babies for early infant diagnosis
• The mainstreaming of private hospitals in the national
reporting system for PMTCT testing
• The more supportive monitoring of service delivery
points

Recommendations:
• Ensure a trained and adequate workforce in a sustainable way.
Recommend MCH staff to prepare screening tests with
confirmation tests carried out by laboratories.
• Develop a robust tracking system to track HIV positive
women, and take samples at home for the early infant
diagnosis testing of exposed babies.
• Strengthen district-level coordination with private hospitals to
regularize reporting
• Perform frequent monitoring visits to intensify HIV services at
birthing centers and beyond.

Issues:
• Low access to CD4 count and viral load machines
• Client duplication in service counting
• Lost or deteriorating medical records (recording and reporting)
• Poor supply of opportunistic infections medicines as per
demand
• Inadequate financial support for clients
• Inadequate training and inadequatenumber of staff working in
clinics
• Poor monitoring and supervision of the ART programme.
HIV treatment, care and support

Recommendation:
• There needs to be reliable and consistent access to
viral load testing and CD4 counts. There is only one
viral load facility in Kathmandu. Need to expand.
• A robust, unique identifier system should be
developed to track individual clients within and
across service sites.
• Start an electronic record keeping system with backup
capability. In addition, create a client coding system
to facilitate improved record keeping and continuity
when clients are transferred in or out.

Recommendation:
• Provide a consistent supply of opportunistic infection
medicines.
• PLHIVs face financial problems, but there is insufficient
government support to pay for medical care and treatment. The
government should establish a mechanism to share the
financial burden faced by PLHIVs.
• Provide frequent updated HIV ART training and regular
monitoring of staff on adherence to guidelines. Appoint
adequate staff for the smooth running of the programme.
• Regularly and frequently monitor and supervise all ART
centres for effectiveness and efficient running through site
visits.

Reference
1. Karki S. HIV/AIDS Situatioin in Nepal: Transition to Women.
2008..
2. https://www.avert.org/professionals/history-hiv-aids/overview
3. Sekar R, Mythreyee M. Global scenario of HIV/AIDS:
Declining trend and moving toward cure. Indian journal of public
health. 2016 Jan 1;60(1):59.
4.Fact sheet HIV Surveillance in Nepal.
5.http://www.unaids.org/sites/default/files/media_asset/UNAIDS
_FactSheet_en.pdf.
6. Preventive and social medicine: K Park 23rd edition

Reference
6. Thapa S, Bista N, Timilsina S, Buntinx F, Mathei C. Social and behavioural risk factors for HIV
infection among the wives of labour migrants in Nepal. International journal of STD & AIDS.
2014 Oct;25(11):793-9.
7. Karki J, Shakya S. Problems Faced by Antiretroviral (ARV) Drug Users in Kathmandu. Journal
of Nepal Health Research Council. 2016 Jun 6.
8. Poudel AN, Newlands D, Simkhada P. Economic burden of HIV/AIDS upon households in
Nepal: a critical review. Nepal journal of epidemiology. 2015 Sep;5(3):502.
9. FHI. Stigma and Discrimination in Nepal: Community Attitudes and the Forms and
Consequences Person Living with HIV/AIDS, Family Health International 2004; Nepal Country
Office, Nepal.
10. Bam K, Thapa R, Newman MS, Bhatt LP, Bhatta SK. Sexual behavior and condom use among
seasonal Dalit migrant laborers to India from Far West, Nepal: a qualitative study. PloS one. 2013
Sep 5;8(9):e74903.
Reference

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