La cara oscura del Perú moderno

Health care services in Nepal are weak (WHO, 2007a) and people in the country have almost negligible access to basic health services. There are no national survey records of mortality and morbidity and the available data are limited and un- reliable due to a lack of proper health management systems and insufficient health treatment protocols. The poor health system results in low life expectancy at birth. In 2007, the life expectancy at birth of women was less than that for men;

that is, 59.91 years and 60.43 years respectively, according to (WHO, 2007a).

28 However, an improved health status has since been reported, with life expectancy at birth for males at 66.4% and for females at 67.8% (UNFPA, 2009). Infant and child mortality rates in Nepal are the highest in the world. Infant mortality was 40 per 1000 live births, and the maternal mortality of Nepali women was 830 per 100,000, as recorded by UNFPA (2009). Although efforts have been made to establish primary health care centres nationwide, the health system and its services are not functioning well. The situation of the health care system is worst in rural areas, due to the lack of trained staff, drugs and medicine (WHO, 2007a). Primary health care services are provided at a district level through sub-level posts, health posts, primary care centres and district hospitals. Secondary and tertiary care is provided zonally, and only regional hospitals have special tertiary facilities (WHO, 2007a). Health care in Nepal involves both modern and traditional dimensions. Public hospitals, nursing homes and private clinics tend to be centralized in urban areas however modern health services are hard to access for rural people. The Nepalese government is placing increasing emphasis on the need for the health sector to provide better health services, especially for children and women, the rural population, the poor and the marginalized. Reduction of infant and child mortality, and low cost but high impact services have also been featured in the second long-term health plan 1997-2017 (WHO, 2007a). Respiratory infection and diarrhoea are the two leading killers of children in Nepal, and these are also opportunistic infections for HIV/AIDS (International Labour office in Nepal, 2004). Seven out of ten children die due to diarrhoea, respiratory infection and other diseases like measles or malaria and it is reported that 78,000 children die each year due to malnutrition (International Labour office in Nepal, 2004).

The poor health status is mainly due to unhygienic food and a polluted working environment. Health services are therefore inadequate for most children in Nepal however for street children, the situation is even more difficult since not only do they have reduced access to health care; they also have more health problems.

29 1.3.6 Epidemiological view of HIV/AIDS and STIs in Nepal

The first AIDS case in Nepal was reported in 1988 (World Bank, 2008) . Since then the number of people living with HIV/AIDS has been increasing and the total number of people reported as having HIV in Nepal by August 2011 was 18,535.

Among the total number of reported cases, 11,964 were male and 6,571 were female (National Centre for AIDS and STD Control (NCASC), 2011). Injecting drug users, followed by clients of sex workers and female sex workers were the most affected groups (National Centre for AIDS and STD Control (NCASC), 2011). In 2010 it was reported that less than 1% of the adult population was living with HIV and there was no indication of a generalized epidemic (UNAIDS, 2010).

However, Nepal has undergone a transition from a low level epidemic country to a country with a concentrated epidemic level, which is characterized by an HIV prevalence that consistently exceeds 5% among certain most at-risk groups:

intravenous drug users (IDUs), female sex workers and their clients, and men who have sex with men (World Bank, 2008). Sex workers are considered as the most at-risk group, with migrants also identified as an at-risk group, since they are often the clients of sex workers (UNAIDS, 2010). Among 25,000-34,000 female sex workers in Nepal, an estimated 1.3%-1.6% were living with HIV, and 15-17% of street-based sex workers were living with HIV in Kathmandu Valley (World Bank, 2008). Drug use overlaps with commercial sex and is also driving HIV transmission in Nepal (World Bank, 2008). World Bank (2008) reported that of 46,309 drug users, 61% were injecting drug users and 34% of these people were living with HIV.

National estimates show that around 8% of migrants returning from India are living with HIV (World Bank, 2008). The striking contributory factor for

elevating HIV prevalence in Nepal is girl trafficking (UNAIDS & WHO, 2009), with particular risks for Nepali sex workers in Indian brothels. World Bank (2008)

30 found that about 50% of Nepal’s female sex workers in Indian brothels have HIV, and it is estimated that 2% of their clients are also infected (World Bank, 2008).

The national estimate for MSM (men who have sex with men) and MSW (male sex workers) is 64,000-193,000; the HIV prevalence among MSM in Kathmandu Valley alone is estimated to be 3.3% (World Bank, 2008).

The National Centre for AIDS and STD Control (NCASC) (2009) reported on a 2009 Integrated Biological and Behavioural Surveillance (IBBS) survey among high-risk population groups, which found a significant decline in HIV prevalence among IDUs, and a stable low HIV prevalence among MSM, female sex workers and truckers. The results showed that the HIV prevalence among IDUs was 21%

in Kathmandu, 4% in Pokhara Valley and 8% in the eastern and western Terai.

High prevalence has been reported among MSW compared to non-MSW

(National Centre for AIDS and STD Control (NCASC), 2009). AMDA Nepal, an organization taking care of refugees’ health in Nepal, stated that the incidence of HIV had been found in fifteen refugees inside the Kakarbhitta-based camp, while there were no refugees diagnosed with HIV a few years ago (RSS, 2010).

Save the Children US (2002) reported that nationwide statistics for STIs are not available in Nepal, but the number of people with STIs is increasing with the rise of risky behaviour. The World Bank (2005) also reported a similar finding. In the survey, among the 7% of women and 2% of men who had STIs, only 42% of women and 61% of men had sought medical treatment from a health centre (Ministry of Health and Population, 2007). It should be noted that research on this topic is dated and no recent studies on the prevalence rates of STIs in Nepal are available. In (2002), Save the Children US stated that the number of people

seeking STI treatment increased from 37.5% in 1997 to 55.5 % in 2002 . It is most important that people who have STIs are treated along with their partners,

however the prevalence of partner treatment in the study was low among the section of the population considered most at risk (Save the Children US, 2002).

31 The study also reported that people felt reluctant to seek treatment for STIs.

Poverty, poor access to health services and a large number of men migrating to India seemed to be the major reasons for the prevalence of STIs (Save the

Children, 2001). People considered that having STI was sinful and that they would be stigmatized if they sought treatment (Save the Children US, 2002). These views are linked to cultural and religious beliefs that may be shared by street children and as has been found in other literature, fear of stigmatization can inhibit access to treatments since people fear this may lead to unwitting disclosure of diseases that are associated with moral or social sanction. It may therefore be the case that street children are not only vulnerable because of the lack of availability of treatment and care but that internalised stigma adds a further barrier to

accessing treatment.