A story of HIV/AIDS and drug use in Nepal, and some of the challenges facing its’ people in the years ahead. A unique insight by an INPUD member, Anjay Kumar KC
My early years in the field, I witnessed the AIDS epidemic devastate the youth among the drug using community. I saw friends suffer as they slowly deteriorated, dying far too young without a cure or a clear intervention. We have, however, come a long way.
As a drug user living with HIV/Hep C co-infection and working in the field of HIV/AIDs, I am proud of the achievements gained by both the HIV/AIDS movement and the drug user movement over the years. Mostly, I am proud of the role PLHA* and PUD’s* in the overall AIDS response, made possible through their direct involvement not only as patients, but also as volunteers, community and home care givers, treatment advocates, activists, outreach workers, health assistants, peer educators, counsellors and residential care workers. Their engagement has helped thousands of disadvantaged PLHIVA’s and PUD’s around the world resulting in thousands of lives saved.
“Unfortunately, Nepal has been struggling to sustain the gains let alone make progress.”
Unfortunately, Nepal has been struggling to sustain the gains let alone make progress. I am troubled by what may happen to things like access to newer classes of anti-retroviral drugs, Hep C treatments, drug specific resistance testing, early infant detection, decentralized viral load testing and care & support services. Our inability to keep up with current advances in medicine and our failure to address realities on the ground may curtail our ability to raise the survivability of PLHAs * and PUD’s**. In addition, dealing with the complexities of co-infection from Multidrug Resistant Tuberculosis, Hepatitis C or Cross Drug Resistance in HIV is a whole different ball game.
Hepatitis C is an emerging issue and must be addressed in order to protect the investments on lives made through the provision of HIV related services, especially among HIV positive and Hep C co-infected drug users on ART. Bearing the government’s track record of health service provision in mind and given the current gap in technical, logistical and infrastructural capacity, this is a worrisome topic.
Methadone in the Mountains
The National Mechanism has only begun to mobilize against HIV and AIDS in general but the response to injecting drug use has tended to lag behind. In Nepal, methadone services have been operational since 2007, but out of a total of 6 service sites throughout the country, less than 600 drug users are accessing it. This may be considered as poor service utilization, given the fact that, according to the most recent national data figures, the number of ‘hard drug users’ (see footnote) has almost doubled during the last 6 years to approx 91,534. Nepal has started programs, instigated and funded by international donors; nevertheless, the success of these programs has not dispelled political and popular opposition to treating drug use. Not only are the programs too small to reach the majority of drug users who might wish to access services, these limited programs will cease to be sustainable once donor funding ends. Three decades into the epidemic Nepal has yet to develop a strong public policy foundation to support the drug user community in the context of Human rights.
In practice, imposing abstinence and punitive measures is unfair and inhumane and has only made things worse for everyone involved. Furthermore, it reinforces bitter vindictiveness. If there is one thing that history has taught us through prohibition, people will do what they ultimately want to do and no government or policy, not even jail or death can bend the human spirit or break the human will. Ultimately, no matter how much the war on drugs rages, in the end, people will do what they want to do, and that’s their prerogative, the right to choose, which I believe is supposed to be a basic human right too.
Drug use has always been associated with human history since ancient times. I personally don’t think drug use is so much of an issue, as is the issue of manageability, functionality and sociability; whether a person is able to carry out their duties and responsibilities; is causing others no harm and is using safely. Harm reduction promotes that and of course everyone has to find their own limits and decide for themselves, but that too is a right in itself bearing in in mind that choices will always be attached superior and inferior consequences. For me personally, oral substitution therapy and a supportive environment have enabled me to make some small measure of change in my life.
Know your Role in your Evolving Epidemic
To identify the most effective response to and make a greater impact, it is crucial to understand not only the disease epidemiology but the realities on the ground, which create barriers to the accessibility and availability of crucial services. This means ensuring meaningful participation of key populations like drug user’s and PLHIVA, in the design, implementation, and monitoring of programs, including assessing any legal or policy barriers to service access and availability, and designing programs to address those barriers. Programmes should reflect the principle of greater and meaningful involvement. This benefits all involved in the response by making it more effective through reflecting the true and changing needs of target populations.
There has been a shift in paradigm where such process have been increasingly monopolized by top level health professionals, who would assume to know the realities on the ground of this ever changing, dynamic epidemic, without inclusive consultation of target populations for whom resources are specifically mobilized. In Nepal, HIV and Drug Use have mostly been associated with low literacy and poverty and the capacity of targeted populations to meaningfully contribute to these processes has also been an issue. Supporting processes that build the capacity of target populations to be able to capitalize upon these opportunities would further strengthen the response.
“There are newer treatment options for viral hepatitis although cost is still prohibitive – the fight here is against corporate greed.”
Not to be too pessimistic, but realistically speaking, I don’t think that an AIDS free generation is within reach at present, however optimistically the UN bodies, donors and stakeholders try to put it. However, a generation that’s at least free of many, if not most of it’s’ burdens, may well be within reach. The global trend in the progress of HIV/AIDS, Hepatitis C and Opiate Substitution Treatment is impressive. DNA PCR technology is available for early Infant Diagnosis (EID). For treatment failure, drug specific resistance testing is available which can rule out or pinpoint which of the drugs in a triple cocktail regimen are working or failing. Newer classes of ART drugs and treatment options that have lesser side effects and can raise the survivability; reduce the morbidity and mortality of PLHIVs. Ways to clear out viral reservoirs and gene therapy are being explored. There are newer treatment options for viral hepatitis although cost is still prohibitive – the fight here is against corporate greed.
We must continue to introduce broader options for treatment and balance human rights based policies, especially in resource limited settings, if better service utilization, adherence and success rates are to be observed. It is also necessary to implement medical, human rights and legal support, including psycho-social interventions, in a mutually reinforcing manner in order to achieve more holistic and sustainable outcomes in people’s lives, for the many years ahead.
By: Anjay Kumar KC
* PLHIVA – People living with HIV/AIDS ** PUD’s People who Use Drug’s
1) The Government of, Central Bureau of Statistics stated there were 46 389 ‘hard drug users’ in 2006 . A second survey carried out by the CBS with collaboration of the Ministry of Home Affairs state the trend in the number of hard drug users in Nepal to have dramatically increased. The results of this survey showed that there are altogether 91,534 current drug users in 2011 (Nepali calendar is 2069) which is nearly double of 2006. Hard drug users are defined as users of opiates and chemical substances like Cocaine, Heroin, LSD, Morphine, Buprenorphine etc.
Make sure you check out ANPUD, the Asian Network of People who Use Drugs: ANPUD is an issues based membership network that aims to ensure the meaningful involvement of People who Use Drugs in policies & programmes that affect us.