Trends and determinants of HIV transmission among men who inject drugs in the Pokhara Valley, Nepal: analysis of cross-sectional studies.

BACKGROUND: HIV is a major public health issue around the world, especially in developing countries. Although the overall prevalence of HIV in Nepal is relatively low, there are specific sub-populations where the prevalence is far higher than the national average. One of these sub-groups is male people who inject drugs (male PWIDs). In order to understand the reasons for the differences in prevalence, a series of socio-demographic, behavioural and knowledge-based risk factors need to be assessed. METHODS: The study used a series of 7 cross-sectional survey datasets from Pokhara (Nepal), collected between 2003 and 2017 (N = 2235) to investigate trends in HIV prevalence among male PWIDs by socio-demographic and behavioural and knowledge-based risk factors. A series of logistic regression models were conducted to investigate the association between study factors and HIV. RESULTS: HIV prevalence decreased from the levels seen in 2003 (22.0%) and 2005 (21.7%), with the lowest prevalence recorded in 2015 (2.6%), however prevalence has increased in the most recent period (4.9%). A lower risk of HIV was associated with younger age (<=24 years compared to > 24 years, OR = 0.17, 95% CI = 0.10-0.31), being married (OR = 1.91, 95% CI = 1.25-3.02) and shorter duration of drug use (<=4 years compared to > 4 years, OR = 0.16, 95% CI = 0.09-0.29). A higher risk of HIV was associated with low (compared to secondary or higher) education level (OR = 2.76, 95% CI = 1.75-4.36), a lack of addiction treatment (OR = 2.59, 95% CI = 1.64-4.08), and recent use of unsterilized injection equipment (OR = 2.22, 95% CI = 1.20-4.11). CONCLUSION: The prevalence of HIV in male PWIDs in Pokhara has been variable, but overall has reduced in recent years to 2.6% before increasing in 2017 to 4.9%. The main determinants which increase the risk of HIV among male PWIDs in Pokhara are low education level, a lack of treatment for drug addiction and the recent use of unsterilised equipment. Each of these indicate the need to improve addiction treatment and education programs for intra-venous drug use to aid this key population in avoiding risk-taking behaviours.

Prevalence of HIV, syphilis, and assessment of the social and structural determinants of sexual risk behaviour and health service utilisation among MSM and transgender women in Terai highway districts of Nepal: findings based on an integrated biological and behavioural surveillance survey using respondent driven sampling.

BACKGROUND: Men who have sex with men (MSM) and transgender people are disproportionately affected by HIV and sexually transmitted infections. MSM and transgender people in Nepal experience considerable discrimination and marginalisation, they are subject to abuse from legal authorities and suffer from mental health issues. These social and structural factors can lead to increased sexual risk behaviour, barriers to accessing health care and result in adverse health outcomes. This study aims to assess the prevalence of HIV and syphilis, and how individual and socio-structural factors influence sexual risk behaviour and health care service uptake, among MSM and transgender women in the Terai highway districts of Nepal. METHODS: A cross-sectional survey was conducted in June 2016 in eight Terai highway districts of Nepal, recruiting 340 MSM and transgender women through respondent driven sampling. The primary outcome variables were HIV and syphilis prevalence. The secondary outcome variables were sexual risk behaviour and health care service uptake. Logistic regression models were used to assess the individual and socio-structural determinants of sexual risk behaviour and health care service uptake. RESULTS: The prevalence of HIV among MSM was 5%, whereas it was 13% in transgender women. The prevalence of active syphilis was 4% in MSM and 11% among transgender women. Among transgender women, 76% were involved in sex work, and 51% had experienced discrimination in one or more settings. In multivariable analysis, having visited an outreach centre was positively associated with condom use in the last sexual encounter among both MSM (AOR: 5.37, 95% CI: 2.42-11.94, p < 0.001) and transgender women (AOR: 2.37, 95% CI: 1.12-5.02, p = 0.025). Moreover, transgender women who reported being open towards family about sexual identity/behaviour were 2.4 more likely to have visited an outreach centre (AOR: 2.40, 95% CI: 1.04-5.57, p = 0.041). CONCLUSIONS: The high prevalence of HIV and syphilis, as well as indicators of marginalisation and discrimination among transgender women, highlights the increased burden transgender women in Nepal are facing and the need for tailored interventions. Moreover, since health care service uptake is an important factor in determining sexual risk behaviour among MSM and transgender women in Nepal, outreach services should be scaled up.

Effectiveness of interventions for changing HIV related risk behaviours among key populations in low-income setting: A Meta-Analysis, 2001-2016.

The aim of this review was to conduct a meta-analysis to assess the effectiveness of behavioural interventions to reduce HIV-related risk behaviours among key populations: people who inject drugs, female sex workers, men who have sex with men and transgender in Nepal over the last two decades. Using four electronic databases, we performed a systematic search of the literature on HIV interventions implemented in Nepal and published from January 2001 to December 2016. In addition, grey literature was also scrutinised for potential articles. The search focussed specifically on behavioural interventions (peer education and HIV testing services) targeted for key populations. Random-effects models were used to calculate the pooled odds ratio for dichotomous outcomes (condom use in last sex or unsafe injection practices), pooled HIV prevalence and subgroup analyses by age groups and epidemic zones in Nepal. Forty-three studies with 15,642 participants were included (people who inject drugs: 7105; men who have sex with men and transgender: 2637; female sex workers: 5900). Pooled prevalence showed a higher occurrence of HIV among people who inject drugs (12%) followed by men who have sex with men/transgender (5%) and female sex workers (2%) respectively. There was a significant increase in the odds of condom use among female sex workers, men who have sex with men and transgender who received peer education interventions in both informal and formal setting compared to those who did not. Similarly, the odds of condom use among female sex workers, men who have sex with men and transgender improved significantly among those who received HIV counselling and testing services as compared to those who did not use such services. Subgroup analyses also verified the effectiveness of these interventions for both young and adult key populations and across all three epidemic zones. However, none of the included interventions were found to be effective for reducing unsafe injection practices among people who inject drugs. HIV prevention interventions in Nepal have effectively reduced risky behaviours among female sex workers, men who have sex with men and transgender over the last two decades but not among people who inject drugs. This calls for continued implementation of existing efforts as well as for new interventions adapted to the needs of people who inject drugs.

HIV awareness and safe sexual behaviors among female sex workers in Kathmandu valley of Nepal.

PURPOSE: Knowledge on HIV and safe sex practices are the main determinants for the prevention and control of HIV/AIDS transmission. The aim of this study was to assess HIV awareness and safe sexual behavior among the female sex workers (FSWs) in the Kathmandu valley of Nepal. METHODS: The study was based on data secondary to Integrated Biological and Behavioral Surveillance surveys of 2093 FSWs in Kathmandu valley from 2006 to 2015. Bivariate and multivariate logistic regression models were used to identify the factors associated with knowledge and misconceptions about HIV (BCDEF) and safe sexual practices (consistent condom use with regular clients and nonpaying partners). RESULTS: FSWs who had secondary education (adjusted odds ratio [AOR]=2.08, 95% confidence interval [CI]=1.60, 2.70) and visited the drop-in center (DIC) (AOR=1.34, 95% CI=1.02, 1.75) in the last year had more knowledge and misconceptions about HIV (BCDEF). FSWs who had consistent condom use with nonpaying partners (AOR=1.60, 95% CI=1.23, 2.09), had a HIV test (AOR=1.34, 95% CI=1.02, 1.76), met peer educators (PEs) (AOR=1.49, 95% CI=1.17, 1.91) and visited the DIC in the last year (AOR=1.32, 95% CI=1.01, 1.72) had a higher chance of condom use with clients. Married FSWs (AOR=2.23, 95% CI=1.57, 3.17) and FSWs who met PEs in the last year were more likely to have condom use with nonpaying partners (AOR=1.42, 95% CI=1.04, 1.93). CONCLUSION: Knowledge and misconceptions about HIV has decreased over the years among FSWs; however, consistent condom use with regular clients and nonpaying partners has significantly increased. HIV intervention programs were strongly associated with safe sexual practices among FSWs and need to be strengthened.

Why don't key populations access HIV testing and counselling centres in Nepal? Findings based on national surveillance survey.

OBJECTIVES: To assess the demographic, behavioural, psychosocial and structural factors associated with non-utilisation of HIV testing and counselling (HTC) services by female sex workers (FSWs) and men who have sex with men/transgender (MSM/TG). METHODS: This study involved a cross-sectional design. We used the national surveillance survey data of 2012, which included 610 FSWs and 400 MSM/TG recruited randomly from 22 and three districts of Nepal, respectively. Adjusted prevalence ratio (aPR) and 95% confidence interval (CI) using modified Poisson regression was used to assess and infer the association between outcome (non-utilisation of HTC in last year) and independent variables. RESULTS: Non-utilisation of HTC in the last year was 54% for FSWs and 55% for MSM/TG. The significant factors for non-utilisation of HTC among FSWs were depression (aPR=1.4 (95% CI 1.1 to 1.6)), injectable drug abuse (ever) (aPR=1.4 (95% CI 1.1 to 1.8)), participation (ever) in HIV awareness programmes (aPR=1.2 (95% CI 1.0 to 1.4)), experience of forced sex in previous year (aPR=1.1 (95% CI 1.0 to 1.3)) and absence of dependents in the family (aPR=1.1 (95% CI 1.0 to 1.3)). Non-utilisation of HTC among MSM/TG had significant association with age 16-19 years (aPR=1.4 (95% CI 1.1 to 1.7)), non-condom use (aPR=1.2 (95% CI 1.0 to 1.4)), participation (ever) in HIV awareness programmes (aPR=1.6 (95% CI 1.3 to 2.0)), physical assault in previous year (aPR=1.8 (95% CI 1.0 to 3.1)), experience of forced sex in previous year (aPR=0.5 (95% CI 0.3 to 0.9)). CONCLUSION: Although limited by cross-sectional design, we found many programmatically relevant findings. Creative strategies should be envisaged for effective behavioural change communication to improve access to HIV testing. Psychosocial and structural interventions should be integrated with HIV prevention programmes to support key populations in accessing HIV testing.

Social determinants and risk behaviors associated with prevalent Hepatitis C and HIV/HCV co-infection among male injection drug users in Nepal.

BACKGROUND: Nepal is facing double burden of injecting drug use and HIV, yet the problem of Hepatitis C Virus (HCV) has not been so well addressed, where there is large population known to be at risk for HCV. This study assessed the prevalence of HCV infection and HIV/HCV co-infection among male injection drug users (IDUs) in Nepal and identified factors associated with infection. METHODS: Cross-sectional surveys in 2015 aimed to sample 1045 male IDUs in the Kathmandu valley, Pokhara Valley and Eastern Terai districts of Nepal. Information about socio demographic characteristics, injecting and sexual risk behaviours were obtained, and biological specimens tested for HCV and HIV. The logistic regression model was used to identify the determinants associated with HCV and HIV/HCV co-infection. RESULTS: HCV prevalence was 28.8% and HIV/HCV co-infection was 4%. Among the 6% of HIV positive male IDUs, 65% were found to be co-infected. The multivariate logistic analysis revealed that HCV prevalence was higher in Eastern Terai districts, longer duration of drug use and injecting drugs and presence of HIV. Similarly, HIV/HCV co-infection was associated with Eastern highway districts, older age and longer duration of injecting drugs. CONCLUSION: The factors strongly contributing to HCV and HIV/HCV co-infection was longer duration of injecting drugs. Highest HCV and HIV/HCV co-infection was found in Eastern Terai districts. Target health interventions need to be focused in Eastern Terai districts and IDUs with longer duration of injecting drugs for the prevention of HCV and HIV/HCV transmission.

Sexual risk behaviors, HIV, and syphilis among female sex workers in Nepal.

PURPOSE: Female sex workers (FSWs) are a key-affected population susceptible to acquiring HIV and sexually transmitted infections (STIs), as well as transmitting the virus to others. The aim of the study was to assess HIV and syphilis prevalence among FSWs in Nepal and to examine factors associated with it. MATERIALS AND METHODS: The study was based on Integrated Biological and Behavioral Surveillance (IBBS) surveys among FSWs in Nepal from 2004 to 2015. Statistical analysis used chi-squared test to assess statistically significant risk factors for HIV and syphilis. Logistic regression models were used to identify the most important determinants for each outcome. RESULTS: A total of 5,958 FSWs were tested, and among them, 100 (1.7%) were HIV positive and 230 (3.9%) were syphilis positive. The multivariate analysis revealed that syphilis was higher among those street-based, aged ≥35 years, illiterate, and with a duration of sex work of >3 years. HIV was higher among those aged ≥35 years, illiterate, street-based, and with a duration of sex work >3 years. Syphilis was strongly correlated with HIV. CONCLUSION: HIV epidemic among FSWs in Nepal appears in the stagnant trend, whereas STI epidemic has increased in recent years. The high influencing factors for HIV and syphilis prevalence were advanced age, street-based, lower education, and longer duration of sex work. Urgent efforts, as part of routine HIV/STI prevention and intervention, are required to reduce the high burden of syphilis among FSWs.

Epidemiology of HIV, programmatic progress and gaps in last 10 years in Nepal.

BACKGROUND AND OBJECTIVES: Nepal has made progress with the control of HIV infection in recent years. There have been changes in epidemiology, programme interventions in different population groups, and changes in policies over the last 10 years, particularly in diagnosis and treatment. Therefore, this review was conducted to identify the effectiveness of different interventions/policies in different sub-populations at risk, targeted towards epidemiology and treatment outcomes for those with HIV infection in Nepal. METHODS: This review was prepared based on a review of published and unpublished documents from the Nepalese HIV infection control programme, published articles in different journals, different survey reports including integrated bio-behavioural surveillance (IBBS) survey reports. RESULTS: The prevalence of HIV infection among adults in 2014 was 0.20% with a progressive decreasing trend from 2005. The prevalence of HIV infection among injecting drug users (51.7% in 2005 and 6.4% in 2015 in Kathmandu valley) was relatively high in all years as compared to other risk groups. HIV infection prevalence among women attending antenatal clinics was higher in the year 2006 (0.25%) but there was a decreasing trend in the following years to 2015, when prevalence was 0.077%. Although different interventions were conducted to cover key populations at risk, the coverage in some risk population was very low. HIV testing status among the general population was very low (7.5% among males and 2.9% among females) in 2011. Only one-third of HIV-infected individuals were on ART in 2015, although this proportion has increased since 2005. The share of domestic budget among the total expenditure on HIV control program is below 15%. CONCLUSIONS: There is the need for implementation of control programmes more efficiently and effectively with expanding geographical and population coverage. Surveillance systems should be strengthened to get up-to-date information for evidence-based planning and developing strategies. The domestic budget for HIV control programme should be increased to improve their sustainability.