1. Overview of HIV Epidemic
Situation in Nepal
Deepak Kumar Karki
National Centre for AIDS and STD Control
Teku, Kathmandu

2. Outline
 Epidemiology of HIV in Nepal
o Epidemic burden (in terms of classical epidemiological
parameters)
o Drivers of HIV risk
 Efforts to curve HIV infections
 New directions
www.nepalaids2012.org.np

3. Current situation of HIV in Nepal
Estimated HIV
infections in 2011:
50,288
www.nepalaids2012.org.np

4. Nepal 2011 HIV Infections Estimates
35,000
30,000 29,052
Male
25,000
Female
20,000
15,000 14,186
10,000
5,000 3,023 2,095 2,444
1,953 1,852
802
0
0-14 years 15-24 years 15-49 years 50+ years
www.nepalaids2012.org.np

5. HIV Age Distribution, 2011
Of total infections:
 Children (0-14) = 8 %
 Female (15-49) = 28 %
 Male (15-49) = 58 %
www.nepalaids2012.org.np

6. Nepal 2011 HIV Infections Estimates
Estimated HIV Proportion
Population Groups
Infections (15-49 years) (%)
People who Inject Drugs (PWIDs) 939 2.2
MSW, TG and Clients 3,099 7.2
Other MSM who do not sell and/or buy sex 6,245 14.4
Female Sex Workers (FSWs) 647 1.5
Clients of FSWs 1,915 4.4
Male Labour Migrants 11,672 27.0
Remaining Male Population 6,914 16.0
Remaining Female Population 11,808 27.3
Total 43,239 100.0
www.nepalaids2012.org.np

7. Distribution of Estimated HIV
Infections by Epi-Zones in Nepal
16%
18%
50% 16%
Source: National Estimates of HIV Infections, 2007
www.nepalaids2012.org.np

8. Distribution of Reported HIV Infections by
Epi-Zones in Nepal, 2010-2011 (4,075)
10%
8%
63% 19%
Source: NCASC:2010 and 2011; Reported HIV infections
www.nepalaids2012.org.np

9. Distribution of key populations at higher risk
(FSWs, MSM/TG and PWIDs), 2010
HUMLA FSW Sizes by districts HUMLA IDUs Sizes by districts
DARCHULA DARCHULA
BAJHANG BAJHANG
MUGU MUGU
BAITADI BAITADI
BAJURA BAJURA
DADELDHURA DADELDHURA
JUMLA JUMLA
DOTI DOTI ACHHAM KALIKOT DOLPA
ACHHAM KALIKOT DOLPA
MUSTANG
MUSTANG KANCHANPUR
KANCHANPUR
DAILEKH
DAILEKH JAJARKOT
JAJARKOT
KAILALI
KAILALI
RUKUM MANANG
RUKUM MANANG
SURKHET
SURKHET
MYAGDI
MYAGDI SALYAN
SALYAN BARDIYA BA
BARDIYA BA GL GORKHA
GL GORKHA ROLPA UN KASKI
ROLPA UN KASKI G
G LAMJUNG
LAMJUNG
PARBAT RASUWA
PARBAT RASUWA N
HA
AN BANKE UT
BANKE TH PY
YU I GULMI
P
HI GULMI CH
NC
DANG AN SYANGJA SINDHU-
DANG
HA SYANGJA KH TANAHU
TANAHU SINDHU- HA NUWAKOT PALCHOK
AK NUWAKOT G
GH
PALCHOK AR PALPA
AR PALPA DHADING KATHM
DOLAKHA
DHADING DOLAKHA
KATHM NAWAL SULUKHUMBU
KAPILBASTU RUPANDEHI BHAK
NAWAL BHAK SULUKHUMBU PARASI
KAPILBASTU RUPANDEHI SANKHUWASABA
PARASI TAPLEJUNG
SANKHUWASABA TAPLEJUNG CHITWAN MAKAWANPUR LALIT KAVRE RA
CHITWAN MAKAWANPUR LALIT KAVRE RA ME
ME CH
CH H AP
H AP OKHALDHUNGA
OKHALDHUNGA PARSA
M
SINDHULI
HU
PARSA KHOTANG BHOJPUR
RAU
R
M
AT
SINDHULI
HA
HU
KHOTANG BHOJPUR
RH
R
RAU
R T
AT
DH
HA BARA
HE
TAH
TE
RH
AN
A A
T
NC
DH
BARA
HE
TAH
TE
H
KU
MAHOTTARAI
U
UDAYAPUR PA
AN
SARLAHI
NC
TT
T
KU
101-500
MAHOTTARAI
A
U
AT SARLAHI UDAYAPUR PA Upto 100
TT
DH
T
101-500
A
Upto 100
AN
DH
ILAM
HA
U
US
501- 1000 Over 1000 SIRAHA
NU
ILAM
A
501- 1000 Over 1000 SIRAHA
S
SA
SUNSARI MORANG
SAPTARI
SUNSARI MORANG
SAPTARI JHAPA
JHAPA
HUMLA MSM Sizes by districts
DARCHULA
BAJHANG
MUGU
BAITADI
BAJURA
DADELDHURA
JUMLA
DOTI ACHHAM KALIKOT DOLPA
MUSTANG
KANCHANPUR
DAILEKH
JAJARKOT
KAILALI
RUKUM MANANG
SURKHET
MYAGDI
SALYAN
BARDIYA BA
GL GORKHA
ROLPA UN KASKI
G
LAMJUNG
PARBAT RASUWA
N
HA
BANKE UT
PY I GULMI
CH
DANG AN SYANGJA SINDHU-
KH TANAHU
G HA NUWAKOT PALCHOK
AR PALPA
DHADING DOLAKHA
KATHM
Source: Population size
RUPANDEHI NAWAL BHAK SULUKHUMBU
KAPILBASTU
PARASI
SANKHUWASABA TAPLEJUNG
CHITWAN MAKAWANPUR LALIT KAVRE RA
ME
CH
H AP
OKHALDHUNGA
estimation of MARPs, 2010
PARSA
M
SINDHULI
HU
KHOTANG BHOJPUR
RAU
R
AT
HA
A T
RH
T
DH
BARA
HE
TE
AN
AHA
NC
KU
MAHOTTARAI
SARLAHI UDAYAPUR PA
TT
T
101-500
A
Upto 100
DH
AN
ILAM
US
501- 1000 Over 1000 SIRAHA
A
SUNSARI MORANG
SAPTARI
JHAPA
www.nepalaids2012.org.np

10. Estimated Number of HIV Infections and HIV
Prevalence among Adults : 1985-2015
70,000 1
Estimated HIV Infections
0.9
60,000
Estimated HIV prevalence 0.8
50,288
50,000 0.7
0.6
40,000
0.5 %
30,000
0.4
20,000 0.3
0.2
10,000
0.1
0 0
1992
2004
1985
1986
1987
1988
1989
1990
1991
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
www.nepalaids2012.org.np

11. HIV Prevalence among Adults (15-49 years)
0.30 % (2011)
www.nepalaids2012.org.np

12. Distribution of Adult (15-49) Estimated HIV Infections
among Risk Groups: 1980-2015
70,000 Remaining female population
Remaining male population
Estimated number of infections
60,000 Male labour migrants
Clients of FSWs
50,000
Female sex workers
Other MSM
40,000
MSW, TG and their clients
30,000 People who inject drugs
20,000
10,000
0
1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 2013
www.nepalaids2012.org.np

13. Routes of Transmission among Reported
HIV cases, 2011
87.9% N = 2,060
100%
80% 7.7%
60% 0.2% Mother to child
40% 4.2% Blood and blood products
20% Sharing unsafe needles
0% Sexual transmision
www.nepalaids2012.org.np

14. Routes of Transmission among Reported
HIV cases, 2010 and 2011
201
87.9% 4.2% 0.2% 7.7%
1
201
84.9% 6.7% 0.4% 8.0%
0
75% 80% 85% 90% 95% 100%
Sexual transmision Sharing unsafe needles
Blood and blood products Mother to child
www.nepalaids2012.org.np

15. New HIV Infections by Risk Groups
www.nepalaids2012.org.np

16. New HIV Infections (15+)
<1.1 (2011)
www.nepalaids2012.org.np

17. We can END AIDS
14,000 AIDS related deaths
12,000 New HIV infections
10,000
8,000
6,000
4,000
2,000
0
1985 1988 1991 1994 1997 2000 2003 2006 2009 2012 2015
www.nepalaids2012.org.np

18. Impact so far of ART and PMTCT
16,000
Deaths averted by ART 13494
14,000
Infections averted by PMTCT
12,000
Life years gained by ART and PMTCT 10362
10,000
8,000 7428
6,000 4736
4,000 2776
1872
2,000 1126
68 216 550
0 18
0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
www.nepalaids2012.org.np

19. EFFORTS
• Prevention
– 69% of the total expenditures were on HIV prevention programs
• Behavioural change interventions
– Peer education (informal/formal setting)
– HIV testing and counselling
– Diagnosis and treatment of STIs
– Harm reduction – NSEP, MMT
– PMTCT
• Scaling-up of Antiretroviral therapy
• Health system strengthening and engaging communities
www.nepalaids2012.org.np

20. New Directions
 Current data/information tell us where epidemic was but
not where it is heading; and how it can be changed with
better mix of interventions.
 We are studying key populations at higher risk of HIV (KPHR)
and behavirours but not their needs (health + )
 Do we really trust point estimates of surveillance surveys?
 Or, is it the effect of changing methodologies over the
period of time? In-depth evaluation is needed
www.nepalaids2012.org.np

21. New Directions
• Explore the possibilities to use routine data as a supplemental data source
for HIV surveillance
• Use of existing SDPs to run cost-effective longitudinal studies
– limited data available to establish causality
• Individual level factors are well evaluated but lack evidence on effect of
contextual/structural factors impact on Key Populations at Higher Risk
behaviours
 Illegal sex work; cross-border movement of KPHR
 Incarceration of PWIDs
 Social stigma against male-male sex
 Linkage of health and human rights issues of sexual minorities
www.nepalaids2012.org.np

22. NEW DIRECTIONS
 Individual level factors are well evaluated but lack evidence
on effect of contextual/structural factors impact on KPHR risk
behaviours
 Illegal sex work; cross-border movement of KPHR
 Incarceration of PWIDs
 Social stigma against male-male sex
 Linkage of health and human rights issues of sexual
minorities
www.nepalaids2012.org.np