HIV in Nepal: Is the Violent Conflict Fuelling the Epidemic?

H IV/AIDS has reached alarming proportions in Southeast Asia [1]. The magnitude of the epidemic is projected to exceed that of sub-Saharan Africa in the 21st century [2]. More than 7 million South Asians are currently infected with HIV [3], nearly 5 million of whom are in India [3]. Nepal has had a comparatively lower prevalence of HIV/AIDS compared to other countries in Southeast Asia. Seasonal migration and sexual traffi cking across a porous Indian border [4], fuelled by a bloody Maoist confl ict (see Sidebar), has raised Nepal's HIV prevalence to the second highest in the region after India. In this essay, we characterize the current HIV epidemic in Nepal, look at the ways in which the confl ict may be fuelling the infection rate, and discuss the current local and international response from the health and development community. We argue that there is currently a short window of opportunity to take action to control the HIV epidemic in Nepal—and that inaction will lead to HIV becoming the biggest killer of the young and middle-aged in the next decade. The fi rst case of AIDS was reported in Nepal in 1998 [5]. Most cases of HIV infection in Nepal are HIV-1, although HIV-2 was also recently reported [6]. As of February 2005, the National Center for AIDS and STD Control in Nepal reported that there were 4,755 HIV-positive people and 856 confi rmed cases of AIDS in Nepal [7]. However, because of the poor surveillance systems and the lack of access to quality voluntary counselling and testing services coupled with antiretroviral treatment, these prevalence fi gures are likely to be a gross underestimate [2]. A dramatically higher estimate comes from UNAIDS, which estimated that 62,000 out of a population of 24.1 million in Nepal were living with HIV/ AIDS in 2003 [8]. One in 200 (0.5%) people aged 15–49 years are living with HIV/AIDS in Nepal [8]. About 30% of those infected are female [8]. WHO/ UNAIDS estimates that 940 children are living with HIV and that nearly 13,000 children were orphaned in Nepal due to AIDS at the end of 2003 [5]. The prevalence in the general population may still be low, but it masks an increasing prevalence in several risk groups—the prevalence of HIV/AIDS consistently exceeds 5% in injecting drug users, commercial sex workers, and migrant workers [5]. Among injecting drug users—estimated to be about 30,000 in …