Jhabindra Bhandari

Globally, HIV/AIDS is still a major public health problem. Despite several efforts of prevention and treatment, there are increasing evidences of new HIV infections among key and vulnerable populations in developing countries. The progress to reduce the burden of the epidemic is still slow. More importantly, the COVID-19 pandemic has profoundly impacted on the provision of HIV services in the communities and health systems at large.

In this context, Global AIDS Strategy (2021–2026) aims to close the inequalities that drive the AIDS epidemic and put people at the centre and communities in leadership in order to get the world on track to end AIDS as a public health threat by 2030. The High Level Meeting on AIDS in June, 2021 has envisioned a strategic roadmap to reduce inequalities and root out the social determinants that fuel the epidemic. This will be helpful to develop new national HIV policies and strategic plans for actions.

Significant progress
According to UNAIDS, the significant progress has been achieved in the political declaration, including new targets to ensure that 95 per cent of people at risk of HIV use combination HIV prevention services. There is a clear focus on community-led provision of services including a target to ensure that 80 per cent of prevention services for key populations are provided by communities. After all, ending AIDS as a public threat by 2030 is an overarching goal which is possible with a strong political commitment and effective engagement of governments, civil society, private sector, media, key populations and their networks. Like many developing countries, Nepal is committed to achieving the ambitious global targets of HIV prevention and treatment at large.

In Nepal, the HIV epidemic has evolved from a low prevalence to concentrated epidemic. This means a low prevalence of HIV infection in the general population but a higher prevalence in specific sub-populations such as people who inject drugs, men who have sex with men, transgender, sex workers and male labor migrants, as well as their spouses. The adult HIV prevalence is 0.13 percent. Despite remarkable progress in national response, there are critical needs to reach the unreached key and vulnerable populations and ensure they have easy access to prevention, testing and treatment services in health facilities. The national response is largely shaped by national health and HIV polices, strategic plans, Sustainable Development Goals, Universal Health Coverage, and the Global AIDS Strategy.

In this context, National Centre for AIDS and STD Control (NCASC) is taking lead in overall coordination and management of national HIV programmes with the support from a range of technical partners such as Global Fund, WHO, UNAIDS, UNICEF, USAID, FHI 360, Save the Children, and few others. The technical assistance from the partners has been instrumental in scaling up of HIV services across the country.

In addition, Country Coordination Mechanism (CCM) is a national committee at Ministry of Health and Population which includes representatives of all sectors involved in the response to the HIV, TB and malaria – mainly civil society, government, multilateral and bilateral agencies, and people living with the diseases, the private sector and technical agencies. The role of CCM is crucial in effectively coordinating funding applications to the Global Fund to ensure linkages and consistency between the Global Fund grants and other national health programmes.
A comprehensive review of HIV strategic plan (2016-2021) has suggested that innovative approaches in prevention and treatment are necessary to fast-track the progress in the national response. Health system response needs to be further strengthened with adequate investments in human resources, robust procurement and supply chain management, health infrastructure, strategic information, better coordination and capacity development. There are emerging needs of the roll-out of pre-exposure prophylaxis (PrEP) and scaling up of targeted and differentiated forms of HIV testing such as HIV self-tests and community testing.

Moving forward, the NCASC has recently drafted a new national HIV strategic plan (2021-2026) which seeks to consider a set of evidence-informed strategic actions that are focused on building resilient and sustainable health systems at large. Moreover, the new strategy broadly aims to ensure a consolidated, unified, rights-based and decentralised HIV programme with services that are integrated into the health systems in the federal context.

In the recent years, community-led monitoring (CLM) is a growing priority in national response, This is an accountability mechanism for HIV responses at different levels, led and implemented by community-led organisations of people living with HIV, networks of key populations, other affected groups or other community entities. The CLM is widely used to monitor the quality of health service delivery and other health interventions, including combination prevention and human rights compliance, promotion and protection.

Entrenched inequalities
On the other hand, tackling entrenched inequalities to end the epidemic is easier said than done. More attention is needed for addressing structural barriers, including gender-based violence, gender inequality, stigma and discrimination. The governments, human rights organisations and civil society networks have a crucial role to create en enabling environment for easy access to prevention, treatment and care services in the health facilities.

In the federal context, there are emerging needs to enhance the capacity of provincial and local governments in mainstreaming HIV in their development policies and plans. Multi-sector coordination need to be further strengthened for social advocacy, networking, partnership and resource mobilisation for effective community response. Empowering the young populations in rights-based and gender-sensitive HIV services is crucial in transforming the national AIDS response. .

(Bhandari is senior doctoral research fellow in global health and health systems)