HIV prevalence in Achham is estimated at 1.7 percent, but many residents, who have never left the remote western district, know HIV only as “Bombay [Mumbai] disease”.
Naming HIV after India’s bustling commercial city is considered the most logical explanation for what happened to men who were healthy when they migrated for work and returned home years later sick. The district has supplied cheap migrant labour to cities such as Mumbai for years.
“There's only one main cause for HIV prevalence here and that is men going to India,” said Surja Kunwar, a nurse at Achham District Hospital, near the district capital of Mangalsen. “Men have to migrate and don't know about safe sex and women cannot demand safe sex with their husbands.”
Although HIV prevalence in Nepal’s general population is a low 0.5 percent, the country has been experiencing a concentrated epidemic among high-risk groups such as seasonal migrant workers. The government found that in 2008, 41 percent of all HIV cases in the country were among labour migrants.
Testing and public awareness for HIV are said to be increasing in Achham, where nearly 70 percent of households migrate at some stage, according to the International Labour Organization. An inclusive maternal care programme at district hospitals, which provide women with US$20 if they give birth on-site, has helped control mother-to-child transmission of HIV; the Achham District Hospital reports only 42 cases of transmission since 2005.
But the silence between husbands and wives at home about protected sex - and men's frequent unprotected encounters with sex workers in Mumbai - continues.
Damdar Saud worked in Mumbai as a physical labourer for 16 years before returning to Achham two years ago. He learned he was HIV-positive after his health began to decline last month, and then walked two days to the hospital.
He is now receiving free antiretroviral treatment and feels better, but has not shared any details of his diagnosis or healthcare with his wife.
“Soon I will go home and I will bring my wife back here to get tested,” said Saud. “But I think I know what will be the result. I'm thinking she is positive.”
Kalashi Vishwakarmas, now pregnant with her fourth child, was the last to know that her husband of 10 years was HIV-positive. He, like Saud, worked in Mumbai, but she says she did not know what kind of job he had. She says she never felt comfortable asking about his sexual activity abroad.
She learned of her own HIV-positive status about two years ago, while she was pregnant with her third child and underwent routine testing at the hospital. All her children have since tested negative.
“I never heard of HIV before,” Vishwakarmas said. “My husband kept this secret from me... I wish I would have known.”
|There's only one main cause for HIV prevalence here and that is men going to India ... Men have to migrate and dont know about safe sex and women cannot demand safe sex with their husbands|
Housewives in Achham constitute the highest number of reported persons living with HIV – 60 percent of the 1,141 recorded cases as of 14 May 2011, according to the Ministry of Health and Population's district health office.
Although more people have been getting tested for the virus, the number of people who know their status is still low. About 13 percent of Achham's approximate 300,000 population have been tested, said Krishna Singh, programme supervisor of the national NGO, Working for Access and Creation, in Achham.
Singh estimates that 5,000 Achham residents are HIV positive. About 64,000 people are estimated to be living with HIV in Nepal, meaning the estimated HIV-positive residents of Achham – only one of 75 districts – account for 7 percent of this national prevalence.
An estimated 1,500 children are affected by HIV/AIDS, many orphaned and serving as heads of households in Achham.
Dhunki Nepali says it may be difficult for her three children living with her if she becomes sick. “My family is here but they don't give us anything, they have their own families to take care of,” said Nepali, whose second husband left after he learned she was HIV-positive.
Her first husband, who used to work as a labourer in India and did not tell her when he tested positive, is no longer alive. “I didn't know anything at the time about his status. I was very young,” she explained.
Nepali's oldest son, aged eight, is also HIV-positive, but she is not sure about her toddler's status. She did not reach the hospital – about an hour's walk – for her delivery and gave birth on the side of the road.
Nepali and her son's status has led to further isolation in their community. “Even though people don't say things [about my positive status] I know they talk and they want the children to stay away,” Nepali said.