HIV/AIDS and STI

Background
With the first case of HIV identification in 1988, Nepal started its policy response to the
epidemic of HIV through its first National Policy on Acquired Immunity Deficiency Syndrome
(AIDS) and Sexually Transmitted Diseases (STDs) Control, 1995 (2052 BS). Taking the
dynamic nature of the epidemic of HIV into consideration, Nepal revisited its first national
policy on 1995 and endorsed the latest version: National Policy on Human Immunodeficiency
Virus (HIV) and Sexually Transmitted Infections (STIs), 2011. A new National HIV Strategic
Plan 2016-2021 is recently launched to achieve ambitious global goals of 90-90-90. By 2020,
90% of all people living with HIV (PLHIV) will know their HIV status by 2020, 90% of all
people with diagnosed HIV infection will receive sustained antiretroviral therapy (ART) and by
2020, 90% of all people receiving antiretroviral therapy will have viral suppression.
Overview of the Epidemic
Starting from a ‘low level epidemic’ over the period of time HIV infection in Nepal evolved
itself to become a ‘concentrated epidemic’ among key populations (KPs), notably with People
who - Inject Drugs (PWID), female sex workers (FSW), Men who have Sex with Men (MSM)
and Transgender (TG) People in Nepal. A review of the latest epidemiological data, however,
indicates that the epidemic transmission of HIV has halted in Nepal. The trend of new infections
is taking a descending trajectory, reaching its peak during 2002-2003. The epidemic that peaked
in 2000 with almost 4,455 new cases in a calendar year has declined to 873 in 2017 (reduced by
81%).
This prevalence has dropped from 0.24% (highest level projected in 2005) to 0.15 in 2017 and is
Overall, the epidemic is primarily driven by a sexual transmission that accounts for more than
77% of the total new HIV infections. Making up 3.8% of the total estimated PLHIV (31,020),
there are about 1,192 children aged up to 14 years who are living with HIV in Nepal in 2017,
while the adults aged 15 years and above account for 96.2%. With an epidemic that has existed
for more than two decades, there are 7,020 infections estimated among the population aged 50
years and above (23%). By sex, males account for two-thirds (61%) of the infections and the
remaining more than one-third (39%) of infections are in females, out of which around 73% are
in the reproductive age group of 15-49 years.
External development partners equally support the national response to HIV in Nepal by
providing a substantial amount of resources required for combating HIV. The Global Fund to
Fight AIDS, TB and Malaria (GFATM), United States Agency for International Development
(USAID), United Nations Children’s Fund (UNICEF), WHO, AIDS Health Care Foundation
(AHF) are the external sources that are contributing to the national HIV response.
Policy Environment and Progress in National HIV Response
Introduction

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More than two decades of the HIV epidemic has stimulated Nepal to respond with a number of
policy initiatives. These policy responses have come cross cuttingly from the health sector as
well as other development sectors aiming at creating an enabling policy environment for the
containment of HIV as well as mitigation of the epidemic. Notable policy developments taken
for guiding the national response to HIV are spelt out here.
The National Health Sector Strategy Implementation Plan (NHSS-IP 2016-2021)
Nepal’s HIV and STI response, recognized as a priority one programme by Government of
Nepal, is guided by the ‘National HIV Strategic Plan 2016-2021’, the Sustainable Development
Goals, and the National Health Sector Strategy (2015-2020). National Health Sector Strategy
Implementation Plan (NHSS-IP) operationalizes objectives of Fast-Tracking HIV response to
achieve ambitious 90-90-90 targets by 2020 and ending the AIDS epidemic as a public health
threat by 2030.
National HIV Strategic Plan 2016-2021
The National HIV Strategic Plan 2016-2021, the fifth national strategy with the aim of meeting
the global goal of 90-90-90 by 2020. By 2020, 90% of all people living with HIV will know their
HIV status by 2020, 90% of all people with diagnosed HIV infection will receive sustained
antiretroviral therapy, and by 2020, 90% of all people receiving antiretroviral therapy will have
viral suppression. The National HIV Strategic Plan for the period 2016–2021 is a set of
evidence-informed strategies focused on building one consolidated, unified, rights-based and
decentralized HIV programme with services that are integrated into the general health services of
the country. It builds on lessons learned from implementation of the National AIDS Strategy
2011–2016, its mid-term review and the Nepal HIV Investment Plan 2014– 2016, and it applies
recommendations from the AIDS Epidemic Model exercise and other strategic information from
studies, surveys and assessments.
National Health Sector Strategy (2015-2020)
The Ministry of Health and Population, National Centre for AIDS and STD Control is
accountable for the implementation of the National HIV Strategic Plan, through the public health
service infrastructure at national, regional, district and village level. Its implementation takes
place in coordination with other public entities and the private sector, including services that are
provided by civil society and other nongovernment networks and organizations. Because
financing the HIV response in Nepal relies heavily on external funding that is rapidly declining,
it is imperative that relevant and mutually beneficial public private partnerships be established
and maintained, and that wise, evidence-informed investment choices are made.
The commitment by Nepal of both the global “UNAIDS Strategy 2016-2021,” and the
“Sustainable Development Goals” adopted by the UN General Assembly, include commitments
to Fast-Tracking the HIV response to achieve ambitious 90-90-90 targets by 2020 and ending the
AIDS epidemic as a public health threat by 2030.
Policy Related Activities/Highlights from FY 074/075

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With the aim of effective implementation of the national response to achieve the national goal of
90-90-90, a number of national guidelines also have been put into operation. These include
“National HIV Testing and Treatment Guidelines, 2017”, National Consolidated Guidelines on
Strategic Information of HIV Response, 2017. Prevention of mother-to-child transmission
(PMTCT) Training Manual 2017, HIV Treatment Literacy Training Manual 2017, Pediatrics
Disclosure Guidelines 2017 and National Guidelines on Community Led HIV Testing in Nepal
2017.
HIV Testing Services and STI Management
Introduction
Pursuant to its goal of achieving universal access to prevention, treatment care and support, HIV
Testing Services (HTS) has been a strategic focus in the national response to HIV ever since
Nepal started its response to HIV. The first ever HTS began in 1995 with the approach of
voluntary Client Initiated Testing and Counseling (CITC). Moving further from its previous
approach of voluntary CITC, the national HIV testing and counselling program has been later
widened to include Provider Initiated Testing and Counseling (PITC), as well as CITC as crucial
components of the nation’s fight against HIV. With the expansion of HIV Testing and
Counseling (HTC) sites across the country, there has been parallel development. National
Guidelines on HTC was formulated in 2003 and updated in 2007, 2009 and 2011 and later the
separate guidelines is merged as a comprehensive guideline on treating and preventing HIV in
2014. The community-based testing approach has also been initiated in key population and as
suggested by National HIV Testing and Treatment Guidelines, 2017 Nepal is also moving
forward to implement the community-led testing approach in order to maximize HIV testing
among key populations of HIV.
Human resources for HTC have been trained for public health facilities as well as NGOs-run
HTS sites. Along with HTS, detection and management of Sexually Transmitted Infections
(STIs) have also been a strategic focus and integral part of the national response to HIV ever
since Nepal started its response to HIV. Over the years, STI clinics have been operating across
the country maintaining their linkage to KPs on the basis of the National STI Case Management
guideline which was developed in 1995 and also revised in 2009 and 2014.
Key Strategies and Activities
HIV Testing Services
The National HIV Strategic Plan 2016-2021 envisions rapid scaling up of testing services by
community led/based testing in a non-duplicated manner in targeted locations in a cost-effective
way to ensure maximum utilization with strong referral linkage to a higher level of treatment,
care and support. The National Strategy further prioritizes that the public health system will
gradually take up HIV testing services as an integral part of the government health care service.
The Government of Nepal is promoting the uptake of HIV testing among KPs through targeted
communications and linkages between community outreach and HTS. Likewise, Provider-
Initiated Testing and Counseling (PITC) have been taken to STI clinics, Antenatal Clinic (ANC),

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childbirth, malnourished clinic, postpartum, Family Planning, and TB services. Thus in this
context, the national response, over the years, has seen an expanding coverage of HTS as an
entry point to:
• Early access to effective medical care (including ART, treatment of opportunistic infections
(OIs), preventive therapy for tuberculosis and other OI and STIs;
• Reduction of HIV in all including mother-to-child transmission;
• Emotional care (individual, couple and family);
• Referral to social support and peer support;
• Improved coping and planning for the future;
• Normalization of HIV in society (reduction of stigma and discrimination);
• Family planning and contraceptive services; and
• Managing TB/HIV co-infection.
Detection and Management of Sexually Transmitted infections (STI)
In the context of detection and management of STI, the standardization of quality STI diagnosis
and treatment up to health post and sub-health post level as a part of primary health care services
has been a key strategy in the national response to HIV. This strategy further foresees
standardization of syndromic approach with the referral for etiological treatment when needed.
Strengthening documented linkages (referral of follow-up mechanisms) between behavioral
change communication (BCC) services and HIV testing and counseling, including the
strengthening of linkage between HTC and STI services has been one of the key actions in the
context of the concentrated epidemic of Nepal.
Progress and Achievement
HIV Testing Services
There are 175 HIV Testing and Counseling sites in Nepal that include 39 non-government sites
and 136 government sites operating in the country also maintaining their linkages with KPs as
well as with ART sites as well as PMTCT sites. The HIV testing is higher in Province 5
(100,333), and Sudurpaschim province (68, 439) whereas the percentage of positivity yield is
higher in Province 2 and Province 3.

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Key Challenges/Issues and Recommendations
Issues
 Huge data gap is found in the HIV 
program especially the report from many
sites (Hospitals and NGOs) are yet to be
covered in the electronic IHIMS system.
 The community-based/led HIV testing 
service among key population is mainly
run through NGOs and IHIMS database 
system does not fully cover NGO setting.
 The reporting from the working NGO yet
to be covered in the electronic IHIMS
system
 Low HIV testing coverage among key 
populations (KPs) has been a long-
standing challenge in response to HIV.
 The problem of low coverage is most
prominent for the returning labor 
migrants.
 Expansion of HIV testing sites.
Recommendations
Coordination between IHIMS and service
sites should be strengthened
Coordination between IHIMS and and
NGO should be strengthened.
All the working NGO must be enlisted in
the IHIMS system. So that, the total
testing numbers could be incorporated,
into national system and national figure of
testing can be generated from the one
HMIS sytem.
Effective roll out of Community-led HIV
Testing and Treatment Competence
(CTTC) approach with active monitoring
should be in place.
Provide testing facilities at transit points
as well as destinations of migrant
population.
 The establishment of testing sites in
government institutions should be scaled
up to increase the accessibility of the
service including the community
based/led testing service through NGOs.

Prevention of Mother to Child Transmission for Elmination of Vertical Transmission

(EVT)
Introduction
Nepal started its Prevention of Mother to Child Transmission (PMTCT) program in 2005 with
setting up three sites at:
1) B. P. Koirala Institute of Health Science (BPKIHS), Dharan;
2) Maternity Hospital, Kathmandu
3) Bheri Zonal Hospital, Nepalgunj.
Moving further in this direction, apart from the free provision of maternal ART and prophylaxis
for infants, the National Guidelines on PMTCT have been developed and integrated into

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National HIV Testing and Treatment Guidelines in Nepal, 2017. Human resources, especially
from maternal and child health care, have been trained in alignment with PMTCT services.
Along with that the preparation and updating of training manuals have taken place. Apart from it,
HIV testing has been incorporated into maternal and child health care in the form of PITC.
Tailoring to the needs of HIV-infected infants as well as HIV exposed babies; counselling and
information on infant feeding have been adjusted accordingly.
Key Strategies and Activities
Taking Mother-to-Child Transmission (MTCT) is a potentially significant source of HIV
infections in children in Nepal into consideration; National Strategy aims to eliminate new HIV
transmission by 2021. In the cognizance of existing coverage (61% in 2074/75) of PMTCT, the
current National Strategy envisages the PMTCT programme to be integrated and delivered
through Reproductive Health (RH) and Child Health Services. The National Strategy also
foresees the integration of PMTCT into RH Programme placing it under the aegis of Family
Health Division (FHD). The National Strategy has structured the PMTCT programme around the
following comprehensive and integrated four-prong approach:
• Primary prevention of HIV transmission
• Prevention of unintended pregnancies among women living with HIV
• Prevention of HIV transmission from women living with HIV to their Children, and
• Provision of Treatment, Care and Support for women living with HIV and their children and
families.
Pursuant to the last two elements of the four prong approach, a package with the entailment of
the following services is being provided to pregnant women:
• HIV testing and counseling during ANC, labour and delivery and postpartum
• ARV drugs to mothers infected with HIV infection
• Safer delivery practices
• Infant feeding information, counseling and support,
• Early Infant Diagnosis (EID) of all HIV exposed children at 6 weeks and
• Referrals to comprehensive treatment, care and social support for mothers and families with
HIV infection.
With the collaboration of thehealth facilities at community level, the government of Nepal
launched Community-Based Prevention of Mother to Children Transmission (CB-PMTCT)
program in 2009 taking PMTCT services beyond hospitals and making the services accessible to
pregnant women living in remote areas. The CB-PMTCT program, drawing the leverage of
community support, has found to have increased ANC coverage as well as HTC uptake among
pregnant women (UNICEF 2012). CB-PMTCT programme has been expanded throughout the
country.
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Apart from CB-PMTCT program, adhering to the key actions envisaged by the National
Strategy, the country is scaling up PMTCT service synchronizing with planned ART, HTC /STI,
OI services for ensuring access to a continuum of care and ART to pregnant women with HIV.
Furthermore, linkages have been established between PMTCT sites and KAP targeted
intervention, Family Planning, SRH and counseling services.
Progress and Achievement
Pursuant to its commitment to eliminate vertical transmission of HIV among children by 2021,
Nepal has scaled up it PMTCT services in recent years. As a result of this scale up of PMTCT
sites, the number of women attending ANC and labour who were tested and received results has
increased over the years. Despite this relative increase in uptake, the coverage for PMTCT is still
low (61%) against the estimated pregnancies.
The HIV testing among pregnant women is higher in Province 3 (95,684),and Province 5
(94,128) whereas the percentage of positivity yield among pregnant women is higher in Province
2, than national.
Aiming at the elimination of mother to child transmission, Nepal adheres to Option B+ and
embarks for providing lifelong ART for all identified pregnant women and breastfeeding
mothers with HIV, regardless of CD4 along with prophylaxis treatment for their infants as well.
The rollout of the lifelong treatment adds the benefits of the triple reinforcing effectiveness of
the HIV response: (a) help improve maternal health (b) prevent vertical transmission, and (c)
reduce sexual transmission of HIV to sexual partners.
Early Infant Diagnosis (EID)
Initiatives for Early Infant Diagnosis (EID) of HIV in infants and children below 18 months of
age have been taken with the goals a) of identifying infants early in order to provide them life-
saving ART; and b) of facilitating early access to care and treatment in order to reduce
morbidity. In this context, a Deoxyribonucleic Acid (DNA) Polymerase Chain Reaction (PCR)
testing facility has been set up at National Public Health Laboratory in Kathmandu. Early Infant
Diagnosis (EID) coverage has significantly increase within two months of birth in last four years
due to widely scale up of sample collection in all ART centers and lab staff widely trained to
collect the sample for EID. After the revision of National HIV Testing and Treatment Guideline
in 2017, and implementation of EID testing at birth, by the end of 2017 the EID testing within 2
months of age increased. However, still 40 % of EID cases are being reached after 2 months of
age due to home delivery, diagnosis of HIV mother during post-natal period and breastfeeding
with the support of trained lab personnel at the site.
HIV Treatment, Care and Support Service
Introduction
With a primary aim to reduce mortality among HIV-infected patients, the government, in 2004,
started giving free ARV drugs in a public hospital and that was followed by the development of
first-ever national guidelines on ARV treatment. Since then, a wide array of activities has been

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carried out with the aim of providing Treatment, Care and Support services to People Living
with HIV (PLHIV). Based on National HIV Testing and Treatment Guidelines 2017 county
implemented ‘test and treat’ strategy from February 2017. Necessary diagnostic and treatment-
related infrastructures such as CD4 machines and viral load machines have been set up in
different parts of the country for supplementing ART management program. Human resources
have been trained for Treatment, Care and Support in parallel with the preparation and updating
of training guidelines. People Living with HIV have been empowered aiming at enhancing their
supplementary roles in Treatment, Care and Support.
Progress and Achievement
By the end of 2017, out of 19,702 PLHIV, only 15,260 of them were on ART. Among the total
tested (7,998) almost 90% (7,184) of PLHIV were with their viral load suppressed. The total
cumulative number of PLHIV receiving ART by the end of fiscal year 2074/2075 has reached
the figure of 16,428 (July 2018). Over the years, there have been gradual increases in the number
of people enrolling themselves on ART as well as receiving ARVs.
Out of those who are currently on ART, 92.5% are adults and remaining 7.5% are children, while
male population makes 51.2%, female population 48.3%, and remaining 0.5% are of the third
gender. The number of people on ART is higher in Province 3 (4,512) and Province 5 (3,009).
There are total 73 ART sites across 59 districts till the end of the fiscal year 2074/75 and it
shows that 15% of those ever enrolled on ART died and 10% have been lost to follow-up, while
75% are alive and on treatment.
The Program data (FY074/75) showed that of all the patients registered on ART during the
period, 88% were still actively on ART after 12 months while 82% were still actively on ART
after 24 months of treatment. With the aim of supplementing the ART management program,
CD4 counts testing service are available on 33 different sites. Some of the portable CD4
counting machines have been placed in the hilly districts of Nepal to provide timely CD4 count
service to monitor ARV effectiveness that leads to support PLHIV to sustain quality and
comfortable life. To monitor ART response and diagnosing treatment failure, viral load testing is
recommended for people receiving ART. National Public Health Laboratory (NPHL), Bir
hospital and Seti Zonal Hospital offer viral load test service to the people on ART treatment.
Additionally, the machines for viral load test has been installed in Western Regional Hospital
and Koshi Zonal Hospital and the service will be delivered from these additional sites soon.
With the purpose of early diagnosing of HIV infection among children born to HIV infected
mother early Deoxyribonucleic Acid (DNA) Polymerase Chain Reaction (PCR) test is done at
the National Public Health Laboratory in Kathmandu. The DNA PCR test is done at birth and 6
weeks. This test is recommended for diagnosing HIV status of children below 18 months and for
those whose test result is inconclusive by rapid test.
As of 2074/75, total 6,687 has received CHBC services from 57 covering districts (Table 5.5.8).
In the same context, 52 districts have CCCs across the country which have been delivering their
services to PLHIV.

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Key challenges/Issues and recommendations

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Province level HIV related Services and Indicators
OST sites in Province one
1. Koshi Zonal Hospital, Morang
2. Mechi Zonal Hospital, Jhapa
ART Sites in Province One
1. Bhaktapur Hospital, Bhaktapur
2. Bharatpur Hospital, Chitwan
3. District Hospital, Dhading
4. Sukraraj Tropical & Infectious Disease Control Hospital, Kathmandu
5. Kanti Children’s Hospital, Kathmandu
6. Maiti Nepal, Kathmandu
7. Bir Hospital, Kathmandu
8. Tribhuvan University Teaching Hospital (TUTH), Kathmandu
9. Maternity Hospital, Kathmandu
10. Dhulikhel Hospital, Kavre
11. Sparsha Nepal, Lalitpur
12. District Hospital, Makwanpur
13. Trishuli Hospital, Nuwakot
14. District Hospital, Sindhuli
15. District Hospital, Sindhupalchowk
ART Sites in Province Two
1. District Hospital, Bara
2. District Hospital, Rautahat
3. District Hospital, Sarlahi
4. District Hospital, Mahottari
5. Janakpur Zonal Hospital, Dhanusa
6. Narayani Sub regional Hospital, Parsa
7. Sagarmatha Zonal Hospital, Saptari
8. Ram Kumar Uma Shankar Charity Hospital, Siraha
List of ART sites in Province 3
1. Bhaktapur Hospital, Bhaktapur
2. Bharatpur Hospital, Chitwan
3. District Hospital, Dhading
4. Sukraraj Tropical & Infectious Disease Control Hospital, Kathmandu
5. Kanti Children’s Hospital, Kathmandu
6. Maiti Nepal, Kathmandu

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 7. Bir Hospital, Kathmandu
8. Tribhuvan University Teaching Hospital (TUTH), Kathmandu
9. Maternity Hospital, Kathmandu
10. Dhulikhel Hospital, Kavre
11. Sparsha Nepal, Lalitpur
12. District Hospital, Makwanpur
13. Trishuli Hospital, Nuwakot
14. District Hospital, Sindhuli
15. District Hospital, Sindhupalchowk
List of OST sites in Province 3
1. Tribhuvan University Teaching Hospital (TUTH), Kathmandu
2. Patan Hospital, Lalitpur
3. Richmond Fellowship Nepal (RFN), Chitwan
4. Aavash Samuha, Bhaktapur
5. SPARSHA, Lalitpur
6. Saarathi Nepal, Kathmandu
7. Youth Vision, Kathmandu
8. Youth Vision, Lalitpur
List of ART sites in Province 4
1. Dhaulagiri Zonal Hospital, Baglung
2. District Hospital, Gorkha
3. Western Regional Hospital, Kaski
4. Lamjung Community Hospital, Lamjung
5. District Hospital, Myagdi
6. District Hospital, Syangja
7. District Hospital, Tanahun
8. District Hospital, Parbat
9. Walling PHC, Syanja
List of ART sites in province 5
1. Bheri Zonal Hospital, Banke
2. Rapti Sub Regional Hospital, Dang
3. District Hospital, Bardiya
4. District Hospital, Rolpa
5. District Hospital, Pyuthan
6. District Hospital, Gulmi
7. District Hospital, Kapilvastu
8. Prithivi Chandra Hospital, Nawalparasi
9. United Mission Hospital, Palpa
10. Lumbini Zonal hospital, Rupandehi
11. District Hospital, Rukum

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 12. Bhim Hospital, Rupandehi
13. District Hospital, Arghakhanchi
14. Maharajgunj PHC
15. Rapti Zonal Hospital, Dang
List of OST sites
1. Bheri Zonal Hospital, Banke
2. Lumbini Zonal Hospital, Rupandehi
3. Youth Vision, Rupandehi
List of ART sites in Karnali province
1. District Hospital, Dailekh
2. Mid-Western Regional Hospital, Surkhet
3. Kalikot District Hospital, Kalikot
4. Salyan District Hospital, Salyan
List of ART sites in Province 7
1. District Hospital, Achham
2. Bayalpata Hospital, Achham
3. Kamalbazar PHC, Achham
4. District Hospital, Bajhang
5. District Hospital, Bajura
6. District Hospital, Baitadi
7. Dadeldhura Sub-regional Hospital, Dadeldhura
8. District Hospital, Darchula
9. District Hospital, Doti
10. Seti Zonal Hospital, Kailali
11. Tikapur Hospital, Kailali
12. Mahakali Zonal Hospital, Kanchanpur
13. Chaurmandu PHC, Achham
List of Possible Indicators for Province One, Two, Three, Four, Five and Seven
Impact level Indicators
a) HIV prevalence among key population
b) HCV and HBV prevalence among people who inject drugs
Outcome level indicators
a) Percentage of sex workers reporting condom use with most recent client
b) Percentage of people who inject drugs reporting having used a condom the last time they
had a sexual intercourse
c) Percentage of men reporting the use of condom the last time they had anal sex with a
male partner

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 d) Percentage of migrants aged 15-49 reporting the use of condom the last time they had sex
with non-regular sexual partner

Output level indicators

a) Needle and syringe distributed per person who inject drugs
b) Percentage of individuals receiving Opioid Substitution Therapy who received treatment
for at least six months.
c) Number and percentage of key population who had an HIV test in the past 12 months and
know their results
d) Percentage of key population reached by HIV prevention programmes - (BCC
intervention, condom and lube distribution)
e) Number of key population screened for HIV by trained layperson
f) Percentage of pregnant women with known HIV status
g) Percentage of pregnant women living with HIV who received antiretroviral therapy to
eliminate vertical HIV transmission
h) Percentage of reported congenital syphilis cases (live births and stillbirths)
i) Number and percentage of people living with HIV who are receiving HIV care (Including
ART)
j) Percentage and number of adults and children on antiretroviral therapy among all adults
and children living with HIV at the end of the reporting period
k) Percentage of people living with HIV who are on retained on ART after 12, 24 and 36
months after initiation of antiretroviral therapy
l) Percentage of health facilities dispensing antiretroviral therapy that experienced a stock-
out of at least one required antiretroviral drug in the last 12 months
m) Number (and percentage) of adults and children living with HIV currently receiving care
and support services from outside facilities
n) Percentage of HIV-positive patients who were screened for TB in HIV care or treatment
settings
o) Percentage of TB patients who had an HIV test result recorded in the TB register

Research Article:

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