Dr. Marlyn F. Borromeo is the UNAIDS Country Coordinator and has been working in Nepal for the past 4 years” Visited many parts of Nepal, Dr. Marlyn has contributed a lot to raise the issue of HIV/ AIDS. She spoke to NEW SPOTLIGHT on various issues. Excerpts:
How do you see the present state of HIV/AIDS in Nepal?
Based on the epidemiological figures from the National Center for AIDS and STD Control (NCASC), Nepal seems to be heeding in the right direction towards effectively preventing HIV infection and providing treatment and care to Nepalis living with HIV. The national HIV prevalence among adults is gradually decreasing from 0.52% in 2003, 0.49% in 2007 and 0.33% in 2011. The 2011 estimated HIV infection stands now at around 55,600; in 2007 it was about 69,000 and in 2009 around 65,000. The 2010 prevalence among injecting drug users (IDU) is about 6% in Kathmandu, and this is the only subset of the population now that has more than 5% HIV prevalence rate making Nepal’s epidemic characterized still as “concentrated”. Over 5,000 Nepalis are receiving anti retroviral treatment, with the drugs that treat (but not cure) AIDS. Of course data are never perfect and as the HIV epidemic and its response mature, we continue to improve our tools and methodologies. But still, the signs are good. However, Nepal should not rest on its laurel and be complacent. These gains are so fragile, as we’ve seen in other countries. Nepal has to continue intensifying its prevention and continuum of treatment and care services to really get to zero new infection, zero AIDS-related death and zero discrimination. While intensifying services, a supportive environment for effective program implementation has to be in place. Hence, there is an urgent need also to review and pass the draft HIV bill. Only when all these (program, policies, resources, enabling environment) are in place and is being implemented effectively can Nepal reach its Millennium Development Goals particularly Goal 6 target 7.
People living with HIV have been complaining that their voices are not heard much in the process of preparing national programs. How do you look at it?
At the national level, mainly here in Kathmandu, men and women living with HIV are represented in various decision-making forums such as the Global Country Coordinating Mechanism (CCM), HIV/AIDS and STD Control Board (HSCB), the previous UNDP Project Management Board, the Coalition of AIDS NGO in Nepal (CANN). During the preparation of Global Fund HIV Proposals, lately Round 10- they have provided substantial inputs. So in that sense, their voices and their inputs are not neglected. But there are still some legitimate issues that need to be deliberated upon and addressed accordingly. For example, the social security of single (widow) women and children infected and affected by HIV remains unaddressed. Most single women whose husbands have died of AIDS are ejected from their home by their in-laws leaving them not only penniless but homeless. These compound their daily struggle of living with HIV and taking care of children who are also infected and/or affected by HIV.
How do you see the recent trend of containing HIV? Can Nepal sustain it?
30 years in the epidemic, we now have vast scientific evidences, ground experiences from myriad of settings in the world, and good practice documentations that- unlike in the past, HIV is now universally preventable and AIDS could now be treated. In 2006, the global aim was to prevent new HIV infections and provide continuum of treatment, care and support services to those in need. This year at the June 2011 General Assembly High Level meeting on AIDS in New York, Member States including Nepal, committed to support global initiatives towards “ending AIDS”. So the trend is clear. Can it be sustained in Nepal? My answer is: Why not? If effective programs are continued, intensified and funded; if sound policies will be implemented; and if a supportive and enabling environment will be in place- no doubt Nepal can sustain it.
As new medicines are coming up against HIV, do you believe that it will be cured?
We can continue to hope that soon, one day, a cure to AIDS will be discovered.
In the early 90’s when I was managing AIDS patients in Manila, it was far from my thought that one day scientists will discover treatment. People were dying of opportunistic infections such as TB, pneumonia or gastro intestinal problems. And we were helpless. There was nothing we can do particularly if their CD4 count went down to less than 200 cells per cubic millimeter (mm3) already. It’s so painful to see them dying in our hands, and not being able to do anything anymore. But that is history now. Today, even if we know that HIV infection is very complex and the pathogenesis leading to AIDS is still not fully understood, we have seen how the quality of life of people receiving ARVs had improved tremendously and changed dramatically. When you see a patient who is almost dying before taking ARV, and see the same patient after taking ARV- fully conscious, coherent, ambulatory and talking to you face-to-face, it’s just incredible! Of course, like other medicines, it also has some adverse reactions and some people couldn’t tolerate it.
Nepal’s recent results showed that the number of HIV among IDU and
sex workers decline, what is the status of migrant workers particularly in the far western region of Nepal?
As I said, the methodologies and tools we are using in estimating HIV infections continue to be refined as the quality of our data improves. So aside from just looking at a single absolute number at a given time, it is important to look at the trend over years, and the qualitative factors that affect the spread of HIV. Now based on the reports from NCASC, the HIV prevalence among female sex workers in Kathmandu is almost plateauing at 2% in 2004, 1.4% in 2006, 2.2% in 2008 and 2% in 2010. For IDU, the decline had been dramatic and I understand NCASC is keeping a sharp eye on this and is trying to analyze it.
In the 2010 HIV infection estimates released by NCASC, almost 28% are male labor migrants, and indeed, this is very alarming. There are however, ongoing prevention, treatment, care and support programs for migrant workers in the Far West. In addressing HIV in the context of migration, one needs to carefully look at the whole spectrum of migration process: from pre-departure phase, transit, at the host or destination country, to the re-integration phase upon their return to their communities. Intervention at these phases varies. Researches have shown that high-risk practices to HIV and other sexually transmitted infections for that matter, often happens at the host country. And this is understandably so, since that time they are away from their family, lonely, with friends/peers and have extra money to buy services. So more aggressive programs at the host countries need to be implemented in close collaboration with authorities of the said host countries.
In the UN, we have developed an initiative on “HIV and Migration” and we are now discussing this with our counterpart in India. Hopefully, we can finalize this joint initiative soon and mobilize the needed resources so it could kick-start immediately.
What does Nepal’s country strategy paper needs to address?
Nepal is now preparing the next National Strategic Plan (NSP) on HIV/AIDS for the next 5 years, 2011-2016. This will be informed by the review of the past NSP and the experiences gained and lessons learned, from some other HIV/AIDS initiatives in the country. The HIV response should strategically address where the current epidemic is, and anticipate where it is deemed to be going. Shortly, it should continue to focus on targeted intervention particularly for IDUs and other key affected population. If we could lower the prevalence of IDU to less than 5% in the next couple of years, that would be a great achievement and Nepal will move out from a “concentrated” epidemic category. Prevention of new infections, treatment to all, and provision of continuum of care and support should be the mainstay of the next NSP. It should likewise address issues surrounding access to quality services, including human rights, law and gender and mechanism to coordinate and harmonize a multisectoral response to HIV/AIDS. Also, the national monitoring and evaluation system on HIV/AIDS has to be fully functional.
What is the level of budget and fund available to Nepal?
According to the “Resource Inflow for the HIV and AIDS Program in Nepal, 2010” released by the HIV/AIDS and STI Control Board (HSCB), in 2009 a total of $ 20.5 million was spent for HIV/AIDS program and in 2010, around $ 19.1 million was obligated.
UNAIDS has been playing crucial role supporting Nepal to cope with HIV. How is your organization supporting Nepal?
UNAIDS is an innovative venture of the United Nations, bringing together the efforts and resources of the UNAIDS Secretariat and the 10 Cosponsors, namely, UNHCR, UNCIEF, WFP, UNDP, UNFPA, UNODC, ILO, UNESCO, WHO and the World Bank. In Nepal, aside from the 10 cosponsors, FAO, IOM and UNWomen are also part of the UN Joint Team on AIDS. Our mandate is to support countries achieve its global commitments to zero new HIV infection, zero AIDS-related death and zero discrimination against people infected and affected by HIV. To carry this out, we have an agreed UNAIDS Division of Labor that clearly stipulates what specific thematic area of the HIV/AIDS response each agency will be responsible with, based on each agency’s mandate and comparative advantage. This is our accountability framework.
In Nepal, we will be developing a Joint UN Program of Support on HIV/AIDS that is envisaged to be the UN’s single document articulating our collective support to the country’s National Strategic Plan on HIV/AIDS 2011-2016.