Ensnared by AIDS. David K. Beine
the epidemic grew, fear lessened that AIDS around the world would ever reach the rates seen (or over estimated) in sub-Saharan Africa.46 Prevalence rates grew only modestly among the general population of the world over the next few years, and then came the discoveries and application of ART in the mid to late 1990s. As the pandemic peaked and actually began to decline globally around 2000, some began to question whether AIDS still warranted an “exceptional status” (Smith and Whiteside 2010:47).47 In response, the WHO and UNAIDS announced they would take a common stand against the three deadly communicable diseases of HIV and AIDS, tuberculosis, and malaria (WHO 2000).48 Although political will to fight these epidemics had been established, in 2001 United Nations Secretary General Kofi Annan called for the creation of a global fund to channel additional resources, and in 2002 the Global Fund to Fight AIDS, Tuberculosis, and Malaria (known simply as “The Global Fund”) was established and has become a major conduit for funding for the trio of remaining worldwide epidemics.49
Even though global prevalence rates are now lower than once thought and new HIV infections and AIDS-related deaths are down overall, HIV and AIDS still continues to warrant our attention. Three-quarters of AIDS-related deaths take place in the Sub-Saharan Africa region and the highest prevalence rates are among the productive age group, resulting in a missing generation, which in turn creates huge social issues (e.g., AIDS orphans, grandmothers having to raise their grandchildren, not enough “workers,” etc.). The destruction of human capital retards economic growth in these already poor areas, intensifying poverty and resulting in a higher susceptibility to HIV, which has been linked to malnutrition, a byproduct of poverty. Also, in many of the third-world countries of the world, the co-infective relationship between HIV and TB is concerning (I will talk about this in relationship to Nepal in the next chapter).
Meantime in the West, the cultural model has shifted from a death sentence to a chronic manageable treatment, with a cure even possibly in sight (as noted previously). But even in the developed West there are problems with the increase in new infection rates among some populations as AIDS fatigue has set in and the poor have unequal access to ARVs and HIV education, as noted earlier. And new issues of medical complications associated with antiretroviral treatment and questions about quality of life for some even in developed countries have emerged, placing more realistic parameters upon our expectations for ART.50 In response to the recent trajectory of HIV and AIDS worldwide, the Executive Director of UNAIDS, Michel Sidibé, expresses both hope and concern:
Hope because significant progress has been made towards universal access. New HIV infections have dropped. Fewer children are born with HIV. And more than 4 million people are on treatment.
Concern because 28 years into the epidemic the virus continues to make inroads into new populations; stigma and discrimination continue to undermine efforts to turn back the epidemic. The violation of human rights of people living with HIV, women and girls, men who have sex with men, injecting drug users and sex workers must end. (Sidibé 2009)
And UNAIDS and WHO in their combined AIDS Epidemic Update (2009:8) conclude:
AIDS continues to be a major global health priority. Although important progress has been achieved in preventing new HIV infections and in lowering the annual number of AIDS related deaths, the number of people living with HIV continues to increase. AIDS-related illnesses remain one of the leading causes of death globally and are projected to continue as a significant global cause of premature mortality in the coming decades (WHO 2008). Although AIDS is no longer a new syndrome, global solidarity in the AIDS response will remain a necessity.
Since the first edition of this book (2003), the changing face of HIV and AIDS is certainly evident. HIV-related mortality rates have peaked and the total number of people living with the virus in 2008 was more than 20 percent higher than the number in 2000. At that same time the number of infections had fallen over the preceding eight-year period (and was 30 percent lower than at the epidemic’s apparent peak in 1996). It is clear, however, that our work with HIV and AIDS globally is not done. In this chapter we have looked at AIDS from a biomedical, social and socioeconomic view. We have examined the construction of various cultural models of AIDS around the world noting that each is specifically unique to the social and cultural factors that have influenced their formation. We have also examined the new treatments which are changing the face of AIDS around the world and have also considered the various social and socioeconomic factors that are continuing the gap between the rich and poor and between the West and the rest in their fight against AIDS. Next, we will examine more specifically AIDS in Nepal.
3 : AIDS in Nepal
At the time of the first edition of this book (2003) there were some pretty dire predictions being made regarding the HIV and AIDS epidemic in Nepal. The number of AIDS cases had increased fifteenfold over a three-year period (1990–93) and was expected to reach 100,000 cases by the year 2000 (Suvedi et al. 1994). The total number of HIV-infected persons in South and Southeast Asia had surpassed the total number of infected persons in the industrialized world (Dhalburg 1994), and at the 1996 worldwide conference on AIDS it was estimated that India, Nepal’s giant neighbor, had more HIV-infected persons (3-5 million) than any other country in the world (Spaeth 1996). Given the geographical proximity and historical relationship of trade between India and Nepal, it was expected that AIDS would grow at an alarming rate in Nepal as well. There was also frequent travel of both tourists and nationals between Thailand and Nepal, and Dixit (1996:50) suggested that “Nepal’s overwhelming reliance on tourism for foreign exchange also increases the possibility of easy access for the virus. Nepal has direct links (through sex workers and businessmen) with the two cities with highest and second highest prevalence of HIV infection in Asia—Bangkok and Bombay.”
In 2003, Thailand had one of the highest incidences of HIV infection in Asia (World Health Organization estimated two to four million by year 2000) and migration between Nepal and Thailand seemed likely to further facilitate the spread of HIV and AIDS into Nepal. As one author warned, all of these factors pointed to an expected “coming crisis” for Nepal (Seddon 1995:2).
Ten years later, HIV and AIDS has not become the crisis we had once expected it to become. As mentioned previously, estimates for nearby India were revised downward and the current estimates for Nepal place the prevalence adult rates among the general population at just 0.3 percent (NCASC 2012), well below even the United States. This is better news than the earlier predictions. However, HIV and AIDS in Nepal still warrant our attention. HIV remains a concentrated epidemic among several high risk groups, and the connection in Nepal between HIV and drug resistant51 tuberculosis is very concerning for the future. So, while there has been progress, many of the factors that influence the discrepancy between the west and the rest (spoken of earlier) still impact Nepal as well.
The purpose of this chapter will be to examine in-depth the current HIV and AIDS situation in Nepal. This will include a presentation of the most current epidemiological information as well as a critical examination of the literature published on HIV and AIDS in Nepal. I will discuss the various HIV and AIDS prevention models that have been promoted in Nepal and introduce the major Nepali discourses on HIV and AIDS that have emerged since the AIDS epidemic arrived in Nepal. I will also introduce the key ideas associated with AIDS in the literature—ideas, which we will see in later chapters, have been influential in the creation of a dominant cultural model of HIV and AIDS in Nepal.
3.1 The epidemiological “facts”
The first case of AIDS was identified in Nepal in July 1988 (Suvedi 1998:53). Since then, the numbers have grown slowly but steadily. Or at least we think so. When talking about numbers in the context of Nepal, it is important to make a distinction between estimated HIV cases and reported cases of HIV and AIDS. Figures 3.1 and 3.2 display the latest cumulative estimates reported by Nepal’s National Center for AIDS and STD Control, the agency responsible for tracking such statistics nationwide (NCASC 2012a). Figure 3.3 displays the cumulative reported (i.e., “tested and confirmed”) number to date (NCASC 2012b).
Figure 3.1. 2012 Estimated HIV infections in Nepal: Part one.