Keshab Deuba

Psychosocial health problems associated with increased HIV risk behavior among men who have sex with men in Nepal: a cross-sectional survey.

Background Men who have sex with men (MSM) are marginalized, hidden, underserved and at high risk for HIV in Nepal. We examined the association between MSM sub-populations, psychosocial health problems and support, access to prevention and non-use of condoms. Methods Between September-November of 2010, a cross-sectional survey on HIV-related risk behavior was performed across Nepal through snowball sampling facilitated by non-governmental organizations, recruiting 339 MSM, age 15 or older. The primary outcomes were: (a) non-use of condoms at least once in last three anal sex encounters with men and (b) non-use of condoms with women in the last encounter. The secondary outcome was participation in HIV prevention interventions in the past year. Results Among the 339 MSM interviewed, 78% did not use condoms at their last anal sex with another man, 35% did not use condoms in their last sex with a woman, 70% had experienced violence in the last 12 months, 61% were experiencing depression and 47% had thought of committing suicide. After adjustment for age, religion, marital status, and MSM subpopulations (bisexual, ta, meti, gay), non-use of condoms at last anal sex with a man was significantly associated with non-participation in HIV interventions, experience of physical and sexual violence, depression, repeated suicidal thoughts, small social support network and being dissatisfied with social support. Depression was marginally associated with non-use of condoms with women. The findings suggest that among MSM who reported non-use of condoms at last anal sex, the ta subgroup and those lacking family acceptance were the least likely to have participated in any preventive interventions. Conclusions MSM in Nepal have a prevalence of psychosocial health problems in turn associated with high risk behavior for HIV. Future HIV prevention efforts targeting MSM in Nepal should cover all MSM subpopulations and prioritize psychosocial health interventions.

Survival on antiretroviral treatment among adult HIV-infected patients in Nepal: a retrospective cohort study in far-western Region, 2006–2011

BackgroundThough financial and policy level efforts are made to expand antiretroviral treatment (ART) service free of cost, survival outcome of ART program has not been systematically evaluated in Nepal. This study assesses the mortality rates and determinants among adult HIV-infected patients on ART in Far-western region of Nepal.MethodsThis retrospective cohort study included 1024 (51.2% men) HIV-infected patients aged ≥15 years, who started ART between May 15th 2006 and May 15th 2011 in five ART sites in the Far-western region, Nepal. Follow-up time was calculated from the date of ART initiation to date of death or censoring (loss to follow-up, transferred out, or 15 November 2011). Mortality rates (per 100 person-years) were calculated. Kaplan-Meier and Cox-regression models were used to estimate survival and explore determinants of mortality.ResultsThe median follow-up time was 19.1 months. The crude mortality rate was 6.3 (95% confidence interval (CI) 5.3-7.6) but more than three-times higher in first 3 months after ART initiation (21.9 (95% CI 16.6- 28.8)). About 12% (83% men) of those newly initiated on ART died during follow-up. The independent determinants of mortality were male sex (hazard ratio (HR) 4.55, 95% CI 2.43-8.51), poor baseline performance scale (bedridden <50% of the day during the past month, HR 2.05, 95% CI 1.19-3.52; bedridden >50% of the day during the past month, HR 3.41, 95% CI 1.67-6.98 compared to normal activity), one standard deviation decrease in baseline bodyweight (HR 1.04, 95% CI 1.01-1.07), and poor WHO clinical stage (stage III, HR 2.96, 95% CI 1.31-6.69; stage IV, HR 3.28, 95% CI 1.30-8.29 compared to WHO clinical stage I or II).ConclusionsHigh mortality was observed within the first 3 months of ART initiation. Patients with poor baseline clinical characteristics had higher mortality, especially men. Earlier initiation of ART through expanded testing and counselling should be encouraged in HIV-infected patients.

Experience of intimate partner violence among young pregnant women in urban slums of Kathmandu Valley, Nepal: a qualitative study

BackgroundIntimate partner violence (IPV) is an urgent public health priority. It is a neglected issue in women’s health, especially in urban slums in Nepal and globally. This study was designed to better understand the IPV experienced by young pregnant women in urban slums of the Kathmandu Valley, as well as to identify their coping strategies, care and support seeking behaviours. Womens’ views on ways to prevent IPV were also addressed.Methods20 young pregnant women from 13 urban slums in the Kathmandu valley were recruited purposively for this qualitative study, based on pre-defined criteria. In-depth interviews were conducted and transcribed, with qualitative content analysis used to analyse the transcripts.Results14 respondents were survivors of violence in urban slums. Their intimate partner(s) committed most of the violent acts. These young pregnant women were more likely to experience different forms of violence (psychological, physical and sexual) if they refused to have sex, gave birth to a girl, or if their husband had alcohol use disorder. The identification of foetal gender also increased the experience of physical violence at the prenatal stage. Interference from in-laws prevented further escalation of physical abuse. The most common coping strategy adopted to avoid violence among these women was to tolerate and accept the husbands’ abuse because of economic dependence. Violence survivors sought informal support from their close family members. Women suggested multiple short and long term actions to reduce intimate partner violence such as female education, economic independence of young women, banning identification of foetal gender during pregnancy and establishing separate institutions within their community to handle violence against young pregnant women.ConclusionsDiversity in the design and implementation of culturally and socially acceptable interventions might be effective in addressing violence against young pregnant women in humanitarian settings such as urban slums. These include, but are not limited to, treatment of alcohol use disorder, raising men’s awareness about pregnancy, addressing young women’s economic vulnerability, emphasising the role of health care professionals in preventing adverse consequences resulting from gender selection technologies and working with family members of violence survivors.

Facilitators and barriers for retention in HIV care between testing and treatment in Asia-A study in Bangladesh Indonesia Lao Nepal Pakistan Philippines and Vietnam.

Introduction The need for efficient retention in HIV care is more evident than ever because of the expansion of earlier ART initiation and the shift towards ‘Test and Treat’. This study assesses factors affecting participation in the HIV care cascade among people living with HIV (PLHIV) in the Asia-Pacific Region. Methods A total of 7843 PLHIV aged 18–50 years were recruited using targeted and venue-based sampling between October 1, 2012, and May 31, 2013, across 59 sites in 7 countries (Bangladesh, Indonesia, Lao Peoples Democratic Republic (Lao PDR), Nepal, Pakistan, Philippines and Vietnam). Statistically significant associations between demographic and health system determinants, and various steps in the HIV care cascade were computed using a generalized structural equation model. Results A high proportion of PLHIV (40–51%) presented late for HIV care and delayed linkage to care in all seven countries. However, once PLHIV enrolled in care, retention in the various steps of the care cascade including adherence to antiretroviral treatment (ART) was satisfactory. The proportion still engaged in HIV care at 36 months post HIV diagnosis, varied from 78% in Nepal to >90% in Lao PDR. Similarly, the proportion of ART initiation who also were adherent to ART ranged from 91% in Bangladesh to >95% in Philippines/ Vietnam and from 70% in Lao PDR to 89% in the Philippines respectively. The following factors enhanced the likelihood of ART initiation and high adherence to HIV care and ART: good client-provider communication, high HIV treatment literacy, a referral from a health worker and TB/HIV co-infection. The following barriers were identified: young age, sex work, imprisonment, transgender identity, illiteracy, rural residence, alcohol/ injecting drug use, perceived poor health status, lack of health insurance, fear of confidentiality breach, self-referral for HIV testing, and public hospital as the place of HIV diagnosis. Conclusions HIV programme planners should ensure easy access to HIV testing and earlier linkage to HIV care among PLHIV. In addition, multiple socio-economic and health systems barriers need to be addressed along the HIV care cascade to reach the UNAIDS 90-90-90 target in the Asia-Pacific region.

Risk of HIV infection among men having sex with men in Kathmandu Valley, Nepal.

Despite extensive distribution of free condoms and lubricants to prevent HIV transmission among men having sex with men (MSM) in Nepal, the prevalence of HIV and risky sexual behaviors remain high. The influence of individual-level, social-capital, and social-structural factors on HIV risk has been insufficiently explored in MSM. The authors assessed association of these factors with HIV risk among 150 MSM enrolled using snowball sampling in the Kathmandu Valley. HIV risk was calculated on the basis of number and type of sexual partners and condom use during anal sex. Multivariate analysis showed a high risk of HIV infection was significantly associated with being involved in sex work, having no knowledge of male sexually transmitted infection (STI) symptoms, and having a history of STI symptoms. HIV prevention could be made more effective by targeting MSM who are involved in sex work and by improving their knowledge of male STI symptoms and early diagnosis and treatment.

Optimizing the implementation of integrated biological and behavioural surveillance surveys of HIV in resource limited settings-lessons from Nepal

Abstract Objective To discuss the basic standards for HIV related integrated biological and behavioural surveillance (IBBS) survey implementation, specific challenges of survey management, and to propose brief practical guidelines for management of IBBS surveys in resource limited setting. Methods Two methods were used to address our study objectives: (a) a narrative review of the literature and (b) our experience as participant observer when working on IBBS survey management between July 2012 and January 2013 in Nepal. Results In Nepal, IBBS surveys are conducted among key populations at higher risk of HIV such as people who inject drugs, men who have sex with men, female sex workers, seasonal male labour migrants and truckers (proxy for clients of female sex workers). The involvement of different institutions, people, and procedures makes IBBS survey management-including planning, implementation, sharing of findings and possible uses of survey findings-complicated to perform. In addition, basic survey methods and techniques including respondent driven sampling and two stage cluster sampling, are sometimes not properly performed in practice. Conclusions This study showed that field implementation of some standards methods such as respondent driven sampling and cluster sampling for HIV related estimate or trends used for IBBS survey could be improved. This paper described lessons learnt and may be used as a guiding reference to improve and evaluate IBBS surveys in resource-poor settings also outside of Nepal.

Perceived Discrimination Is an Independent Risk Factor for Suicidal Ideation among Sexual and Gender Minorities in Nepal

Sexual and gender minorities experience an elevated burden of suicidality compared with the general population. Still, little is known about that burden and the factors generating it in the context of low- and middle-income countries. The present study assessed the prevalence of suicidal ideation, planned suicide, and attempted suicide among men who have sex with men (MSM) and transgender people (TG) in Nepal, and examined the association of perceived discrimination on the basis of sexual orientation with suicidal ideation and with attempted suicide. Data were obtained from a surveillance survey among MSM and TG in Nepal in 2012. A sample of 400 MSM and TG, recruited using respondent-driven sampling, completed a structured face-to-face interview. Throughout their lifetime, 26.8% of the participants had experienced suicidal ideation, 12.0% had made a suicide plan, and 9.0% had attempted suicide. In particular, more TG than MSM had experienced suicidal ideation (39.8% vs. 21.3%), had made a suicide plan (19.5% vs. 8.9%), and had attempted suicide (15.3% vs. 6.4%). Overall, the odds of having experienced suicidal ideation was significantly higher among the 38.3% of participants who had perceived discrimination based on their sexual orientation (AOR: 3.17; 95% CI: 1.83–5.48). Moreover, the odds of suicidal ideation was significantly higher as the extent of perceived discrimination increased (AOR: 1.35; 95% CI: 1.15–1.60). However, the odds of attempted suicide was not significantly associated with perceived discrimination (AOR: 1.40; 95% CI: 0.62–3.15). The findings highlight perceived discrimination as an independent risk factor for suicidal ideation. Future suicide prevention programs should target sexual and gender minorities and include elements focusing on discrimination.

Micro-level social and structural factors act synergistically to increase HIV risk among Nepalese female sex workers

OBJECTIVES Sex workers face stigma, discrimination, and violence across the globe and are almost 14 times more likely to be HIV-infected than other women in low- and middle-income countries. In Asia, condom campaigns at brothels have been effective in some settings, but for preventive interventions to be sustainable, it is important to understand micro-level social and structural factors that influence sexual behaviours of sex workers. This study assessed the syndemic effects of micro-level social and structural factors of unprotected sex and the prevalence of HIV among female sex workers (FSWs) in Nepal. METHODS This quantitative study included 610 FSWs who were recruited using two-stage cluster sampling from September to November 2012 in 22 Terai Highway districts of Nepal. Rapid HIV tests and face-to-face interviews were conducted to collect biological and behavioural information. A count of physical (sexual violence and other undesirable events), social (poor social support and condom negotiation skills), and economic (unprotected sex to make more money) factors that operate at the micro-level was calculated to test the additive relationship to unprotected sex. RESULTS The HIV prevalence was 1%; this is presumably representative, with a large sample of FSWs in Nepal. The prevalence of unprotected sex with clients was high (24%). For each additional adverse physical, social, and economic condition, the probability of non-use of condoms with clients increased substantially: one problem = 12% (p<0.005), two problems = 19% (p<0.001), and three to five problems = 38% (p<0.001). CONCLUSIONS Interactions between two or more adverse conditions linked to physical, social, and economic environments increased the risk of unprotected sex among Nepalese FSWs.

Condom use behaviour among people living with HIV: a seven-country community-based participatory research in the Asia-Pacific region

Objectives We examined the prevalence of inconsistent condom use and its correlates among people living with HIV (PLHIV) in the Asia-Pacific region. Methods Between 1 October 2012 and 31 May 2013, a total of 7843 PLHIV aged 18–50 years were recruited using targeted and venue-based sampling in Bangladesh, Indonesia, Lao People’s Democratic Republic (PDR), Nepal, Pakistan, Philippines and Vietnam. Logistic regression was used to explore the association between condom use behaviour and demographics, social support, stigma and discrimination and various health-related variables. Results Overall, 43% of 3827 PLHIV practised inconsistent condom use at sexual intercourse with their regular partner. An even higher proportion, 46% of 2044 PLHIV admitted that they practised unprotected sex with a casual partner. Participants from Lao PDR reported the lowest prevalence of inconsistent condom use for both regular and casual partners, while participants from the Philippines had the highest risk behaviour. Inconsistent condom use was significantly associated with belonging to a key population (drug user, sex worker or refugee subpopulation), not knowing that condoms are still needed if both partners are HIV positive, having a regular partner whose HIV status was either positive or unknown, having experienced physical assault and not receiving antiretroviral treatment. Conclusions This large seven-country study highlights a high prevalence of inconsistent condom use among PLHIV in the Asia-Pacific region. In addition to knowledge-imparting interventions, the adoption and expansion of the ‘Test and Treat’ strategy could help to maximise the prevention benefits of antiretroviral treatment.

HIV decline associated with changes in risk behaviours among young key populations in Nepal: analysis of population-based HIV prevalence surveys between 2001 and 2012.

We assessed changes in HIV prevalence and risk behaviours among young key populations in Nepal. A total of 7505 participants (aged 16–24 years) from key populations who were at increased risk of HIV infection (2767 people who inject drugs (PWID); 852 men who have sex with men/transgender (MSM/TG); 2851 female sex workers (FSW) and 1035 male labour migrants) were recruited randomly over a 12-year period, 2001–2012. Local epidemic zones of Nepal (Kathmandu valley, Pokhara valley, Terai Highway and West to Far West hills) were analysed separately. We found a very strong and consistent decline in HIV prevalence over the past decade in different epidemic zones among PWID and MSM/TG in Kathmandu, the capital city, most likely due to a parallel increase in safe needle and syringe use and increased condom use. A decrease in HIV prevalence in 22 Terai highway districts, sharing an open border with India, was also consistent with increased condom use among FSW. Among male labour migrants, HIV prevalence was low throughout the period in the West to Far West hilly regions. Condom use by migrant workers involved with FSW abroad increased while their condom use with Nepalese FSW declined. Other risk determinants such as mean age at starting first injection, injection frequency, place of commercial sex solicitation, their mean age when leaving to work abroad did not change consistently across epidemic zones among the young key populations under study. In Nepal, the decline in HIV prevalence over the past decade was remarkably significant and consistent with an increase in condom use and safer use of clean needles and syringes. However, diverging trends in risk behaviours across local epidemic zones of Nepal suggest a varying degree of implementation of national HIV prevention policies. This calls for continued preventive efforts as well as surveillance to sustain the observed downward trend.