Nepal

“Drugs were a way to escape from reality. But because of it, I have faced a lot of discrimination,” said Yukusna Kurumbang. “After a while I had no one around me. No friends I could contact. I have my family but they do not trust me. I am trying to improve.” 

There aren’t many resources at Ms. Kurumbang’s disposal. She’s fashioned her own path to recovery including volunteering with YKP Lead Nepal—a youth-led organisation. 

“I’m investing in myself and others to escape drugs,” she explained. “I’m trying to control my mind.” 

The organisation’s President, Rojal Maharajan, recalls the feeling of isolation he too faced while using: “It’s very humiliating—the gossiping and negative comments. My family also got sick and tired of me. Eventually I had no one to tell about my problems and my mental health status.” 

He started his advocacy eight years ago after a successful rehabilitation stint.  

“I wanted to do this work to make sure young people who use drugs are treated as human beings. They deserve to have a good life and better opportunities,” he said. 

These deeply personal perspectives help YKP Lead Nepal respond to the addiction challenge facing Nepal’s youth. And it’s a complex challenge.  

There was a 2021 review of the human rights situation of people who use drugs in Nepal by the International Drug Policy Consortium, Recovering Nepal, YKP LEAD Nepal and Youth Rise International. It notes that the Narcotic Drugs Act criminalises not only drug possession, but addiction itself. According to a 2019 survey of people who use drugs, almost half had been arrested for drug use or a related offence. Among people who injected drugs the arrest rate shot up to 63%.  

Treatment for drug dependence is privatised and inaccessible to most, including residents of border towns where services are most scarce. Among those who have had access to drug treatment, one in ten reports having experienced ill-treatment, violence and even torture.

The Government of Nepal has made progress around the provision of harm reduction services including needle and syringe programmes and opiate agonist therapy (OAT). However there are allegations that police frequently harass and detain people visiting these facilities.  

“Punitive drug policies across the region have created a culture of violence and impunity by law enforcement,” said Ikka Noviyanti, Regional Coordinator of Youth LEAD, the Asia and the Pacific young key population network. “This makes it more difficult for people to reach the range of prevention and treatment services they need to stay safe. The situation is even more dire for youths.” 

A 2019 Ministry of Home Affairs survey determined that over three-quarters of people who use drugs in Nepal are under age 30. Another study found that one-third of young people who use drugs started before age 15, with almost half commencing drug use between 15 and 19. The advocates say that in lieu of heroin which is expensive, there’s a growing trend of young people mixing and injecting tranquilizers like Diagepam, Nitrazepam and Dormin. 

Injecting drug use increases the risk of abscesses as well as illnesses including HIV, Hepatitis B and C. HIV prevalence for injecting drug users is 3% for males and 2% for females. By comparison, Nepal’s adult general population HIV prevalence is 0.1%.  YKP Lead Nepal is advocating for disaggregated data so they can better grasp the scale of the HIV burden carried by young people.  

The organisation shares safety information with clients along with clean needles and syringes. During the Covid-19 lockdowns, for example, they home delivered both food and harm reduction packages. Their outreach includes homeless young people.  

But the advocates say that even when clients are aware of the risks, there are barriers to staying safe.  

“Most of them don’t want to go to the service sites,” Mr Maharajan explained. “Many of the young women have told us they are harassed at the OAT clinics. Others have a concern that the people running the needle exchange programmes are from rehabs. They don’t want to be forced to go (to rehab) because they are fearful of torture.”  

UNAIDS Country Director for Nepal, Masauso Nzima, says that the Government of Nepal has made a move in the right direction with its investment in harm reduction services. However, more needs to be done to ensure a people-centred approach to drug policies “if we are to make a sustained difference in the lives of young people”. 

“A critical step is the adoption of laws that treat drug dependence as a health condition rather than a crime. Action is also needed to outlaw torture and ill treatment, holding violators accountable and providing increased oversight for rehabilitation centres. Finally, we are advocating for expanded access to drug treatment and harm reduction programmes, without discrimination,” Mr Nzima said. “That means young people, women and people living in all parts of the country should have equitable access.” 

YKP Lead Nepal goes a step further, calling for designated days for young women to access harm reduction services and for young people to be among the service providers.  

With support from UNAIDS Asia Pacific, Youth LEAD is now piloting a “Regional Healthcare Worker Training Manual: Friendly HIV and SRHR services for young key populations in Asia Pacific”. The approach is meant to address the multiple barriers to young key populations accessing services including concerns about privacy and confidentiality, stigma and discrimination among healthcare providers, inconvenient opening hours and service packages that do not speak to their specific needs. 

“Young people account for one of four new HIV infections in Asia and the Pacific,” Ms. Noviyanti said. “We are failing young people. But with targeted investments for youth-led responses and action we can turn the tide.”

Wang Tang (not his real name) had never been to Nepal before, but at the end of March 2020 it was one of the few countries that had not closed its borders with China. Since he was desperate to get away from Beijing after having had to stay at home for months after the coronavirus outbreak spread throughout China, he bought a ticket.

But days after he arrived, while he was staying in Pokhara, the fourth stop on his trip, the local government announced that the city would be shut down. He heard that the lockdown would not last longer than a month.

As someone who is living with HIV, he had brought along enough HIV treatment to last for a month. However, he soon learned that the re-opening of the city was to be postponed, which meant that he was at risk of running out of the medicine he needed to take regularly in order to suppress his HIV viral load and stay healthy.

Mr Wang swallowed hard while counting the remaining tablets. He had no idea how to get more.

As the lockdown dragged on, it seemed that no end was in sight. Mr Wang started to take his medicine every other day so that his supply would last a little bit longer.

He contacted his friends back at home, hoping that they could send medicine to Nepal, but they couldn’t. The country was under lockdown—nothing could be imported.

Then, Mr Wang contacted his friend Mu-Mu, the head of Beijing Red Pomegranate, a nongovernmental organization providing volunteer services for people living with HIV. It was with Mu-Mu’s help that Mr Wang learned how to obtain HIV treatment after he was diagnosed as living with HIV. Having known each other for many years, Mu-Mu had the trust of his friend. Mu-Mu contacted the UNAIDS Country Office for China to see if it was possible to deliver medicines to Mr Wang. A UNAIDS staff member quickly got in touch with the UNAIDS Country Office for Nepal.

Everything happened so quickly that Mr Wang was shocked when he received a message from Priti Acharya, who works for AHF Nepal and had been contacted by the UNAIDS Nepal office, saying that she would bring the medicine to him.

The next day, Ms Acharya rode her motorbike for 15 km on a dusty road before reaching the place where she would meet Mr Wang. When he came down from the mountains to meet her, Ms Acharya, drenched in sweat, was waiting under the midday sun.

“I was so happy and thankful for her hard work. She gave me a sunny Nepalese smile in return, as well as detailed instructions on the medicine’s dosage,” said Mr Wang.

They took a photograph together, then Mr Wang watched Ms Acharya as she left on her motorbike. Her image, disappearing in the distance, is carved into his memory. To attend the five-minute meeting, Ms Acharya had to ride a round trip of more than 30 km.

“For half a month or so, I had been suffering from pain and anxiety almost every day due to the lack of medication and the loneliness of being in a foreign country on my own. I could not believe that I got the HIV medicine in such a short time,” said Mr Wang. After the trip, he wrote to thank Ms Acharya, explaining how important the medicine he now had in his hand was: “it’s life-saving.”

At the end of his stay in Nepal, Mr Wang wanted to do something for UNAIDS. As he is an experienced photographer, he volunteered to carry out a photo shoot for UNAIDS’ Nepal office.

The subject he chose was former soccer player Gopal Shrestha, the face of an HIV charity in Nepal and the first person living with HIV to reach the summit of Mount Everest. After his HIV diagnosis in 1994, Mr Shrestha launched the Step-Up Campaign and spent many years climbing mountains worldwide, hoping to give strength and hope to people living with HIV.

In 2019, Mr Shrestha reached the peak of the world’s highest mountain, Mount Everest, recording a historic breakthrough for people living with HIV. “If 28 000 people have already climbed Mount Everest, why can’t I?" he said. “By climbing the highest mountain in the world, I want to prove that we are no different from anyone else and that we can all make a difference.”

“The moment I saw him, I could tell he was a sophisticated man,” said Mr Wang. Without instructions, Mr Shrestha posed naturally in front of the camera. He displayed confidence and charm. His eyes, content and clear, reflected nature’s beauty. “The eyes surely are the window to the soul,” Mr Wang said.

Mr Wang is looking forward to his next trip to Nepal. After the pandemic, Pokhara’s lakeside will be flooded with tourists, and he looks forward to seeing the mountain town bustling with people like it used to.

From the very beginning, communities were in the vanguard of the AIDS response in Nepal. Still playing a vital role in the response to HIV in the country, communities are making good-quality services more accessible for people living with HIV and key populations and standing up to HIV-related stigma and discrimination.

“Nepal made antiretroviral medicines accessible to all people living with HIV as a result of advocacy efforts led by communities, human rights activists and other national stakeholders,” said Gopal Shrestha, a prominent community leader living with HIV.

Discrimination towards key populations is still deeply rooted in Nepalese society. “Finding people who need services is difficult due to a lack of trust. We work with those communities that fear coming out because of discrimination,” said Simran Sherchan, Operation Head of the Federation of Sexual and Gender Minorities in Nepal (FSGMN).

Although antiretroviral medicines are available to everyone living with HIV in Nepal, a survey conducted in 2018 reveals that more than 30% of transgender people avoid seeking health care because of fear of stigma and discrimination—something that FSGMN is determined to end.

“Community-based organizations play an intricate role in reaching out to those hard to reach,” said Anjay Kumar KC, a community leader who advocates for harm-reduction in Nepal. Recovering Nepal, a community network of people who use drugs, is supporting harm reduction programmes and HIV prevention among young people who use drugs, including a peer-to-peer programme that provides sterile needles and syringes and a campaign that promotes HIV testing. It has also played a key role in advocating with the government to initiate opioid substitution therapy, which is now offered at 12 sites in five provinces in the country.

Community-based organizations mobilize communities to demand services and advocate for their right to health. Recently, the National Association of People Living with HIV/AIDS (NAP+N) successfully advocated to include people living with HIV in the country’s Health Insurance Programme in 57 districts across the country. “NAP+N also entered into an agreement with Prime Life Insurance Limited to guarantee people living with HIV can access life insurance services,” said Rajesh Didiya, President of NAP+N.

Despite these achievements, community-based organizations face challenges. “When I reach out to sex workers, I have to hide my identity, because sex work is still stigmatized by my family and society. That is why it is difficult to publicly raise awareness about sex workers’ rights,” said Bijaya Dhakal, Coordinator of the Nepal Federation of Female Sex Workers.

Parina Limbu, a community leader who advocates for engagement in decision-making by women who use drugs, said, “Being labelled as women who use drugs, women living with HIV and hepatitis and sex workers, we are not within the reach of programmes. Our needs should not be looked at through the lens of males who use drugs. Women who use drugs need more decision-making spaces to make sure that our voices are heard.”

Those challenges can be overcome through partnerships and joint efforts, however. The Right to Health Women’s Group, Right Here Right Now and FSGMN have created a platform to collect and monitor cases of human rights violations against people living with HIV, key populations and young people. They use the evidence that they collect to advocate for programmes on stigma and discrimination reduction in health facilities and raise awareness about the human rights of key populations with law enforcement officers.

UNAIDS in Nepal has played a key role in empowering communities. “The important role that the community plays in the country’s response to HIV should not be underestimated. The gains made are because communities are taking the initiative and acting in ways that ensure that people who need treatment, prevention and related HIV services can access them,” said Masauso Nzima, UNAIDS Country Director for Nepal and Bhutan.

The Right Honorable Prime Minister Jhala Nath Kanal and Mr. Kush Kumar Joshi, Chair of FNCCI, unveil the BCAN logo.
Credit: UNAIDS

Nepal’s AIDS response has received a business boost with the launch of a national Business Coalition on AIDS (BCAN). The Coalition brings together multiple Nepalese private sector companies, leaders, innovators and industrialists to work collectively in the response to AIDS.

The Federation of the Nepalese Chambers of Commerce and Industry (FNCCI) launched the Coalition with the goal of reducing HIV infection among the country’s workforce. It is also expects that the Business Coalition will create a supportive environment for the care and treatment of employees living with and affected by HIV and their families. “This Coalition will work to remove stigma associated with HIV so that people living with HIV do not suffer from discriminatory treatment in the workplace and in society,” said Mr Kush Kumar Joshi, Chair of FNCCI.

In a high-profile event held in Kathmandu in May, Nepalese Prime Minister and Chair of the National AIDS Council, the Right Honorable Mr Jhala Nath welcomed the business sector as vital partners: “The Government of Nepal acknowledges with utmost appreciation this initiative from the business sector to be engaged and contribute to the country’s response on HIV. This is an important part of the business sectors’ response towards the social development of Nepal”.

Pioneered by business leader Mr Rajendra Khetan who also leads the Asia Pacific Leadership Forum on AIDS (APLF), and who for many years has worked to bring AIDS higher on political, business and social agendas, the FNCCI-BCAN already has more than 1 500 members from across the country. These private sector leaders have underlined their commitment to put in place HIV prevention, treatment and care programmes to help maintain a healthy and competitive environment for their workers and their families, including those from key affected communities.

In Nepal, estimated adult HIV prevalence is 0.4% but the country also has a ‘concentrated’ epidemic where estimated HIV prevalence among key affected populations reaches more than 5%. According to latest national reports, more than 85% of the newly reported HIV cases are among people aged 16-45, which is the most economically active age group.

“The most immediate way that business and the new business Coalition can take action is by protecting its greatest resource—its employees. In doing so, the Coalition is investing in the well being and morale of employees and communities, and investing in the sustained growth and development of Nepal,” said UNAIDS Country Coordinator Marlyn Borromeo.

As a first priority, businesses within BCAN commit to ensure the implementation of the National Policy on HIV/AIDS in the Workplace which highlights the need for increased resources and action from the private sector on AIDS and the importance of protecting employees living with HIV and their families.

Ms Sita Shashi, President of Srijanshil Mahila Samuha, an organization of women living with HIV in Nepal, heralded the increased involvement of the business community in Nepal’s HIV response: “[This] has enhanced our confidence that business can bring positive change; ensuring access to HIV prevention, treatment, care and support in workplace; supporting economic empowerment opportunities for women living with HIV in communities and; promoting accepting attitude towards people living with HIV and their families,” she said.