Human Rights Violations and HIV Related Outcomes among Men who have Sex with Men and third gender in Nepal (METRA-SGM Nepal)

Led by Drs. Luke Mullany and Sonal Singh

In Partnership with the Blue Diamond Society of Nepal

Objective and activities: The objectives of this project are: 1) To identify a range of human rights that are enshrined in international law and are commonly reported, by MSM and third genders in Katmandu, to be non-protected or violated, 2) To develop and implement a quantitative survey instrument designed to capture exposure to violations of these human rights, and estimate the prevalence of human rights violations among MSM and third genders, 3) To quantify the association between human rights violations and health behaviors (injection drug use and substance abuse) and outcomes (prevalence of STDs and HIV, anxiety and depression).  To understand the social, behavioral and health risks and the humam rights sitauation for MSM and third genders in Nepal, the study will recruit 840 individuals, 90% of whom are expected to be MSM/third gender by practice, to complete surveys and HIV screens. 

Background: The use of epidemiological approaches to explore the relationship between human rights violations and health outcomes are limited. Providing a direct, rather than the more traditional ecological, perspective to this relationship can complement qualitative data on human rights violations, strengthen the advocacy efforts of rights-oriented organizations, and provide objective population-based information that might guide policy. Furthermore, monitoring of public health programs requires consideration of important covariate factors; such monitoring might be inadequate if exposure to human rights violations is neglected. We have previously applied standard epidemiological methods to provide population-based estimates of the associations between gross human rights violations in eastern Burma and health outcomes including mortality (child and infant), morbidity (child malnutrition, malaria parasitemia, maternal anemia), and access to health interventions (contraceptives, malaria testing). These methods might additionally be applied to health outcomes observed in contexts where “structural” human rights violations are common, and institutional capacity to protect human rights is weak. For example, men who have sex with men (MSM) and third gender in Nepal are a vulnerable group with few legal protections. Specific epidemiological data on the association between human rights violations and health indicators among this sub-population are unavailable but necessary to improve the effectiveness and reach of risk-reduction programs.

The National Strategy for HIV/AIDS in Nepal identifies injecting drug users, commercial female sex workers and MSM as high risk groups,1 with substantially higher HIV prevalence (68%, 18%, 5%, respectively) than the general population (<1%). Among a sample of 358 MSM in Katmandu in 2005, only one-third correctly identified ways of preventing sexual transmission of HIV, and HIV prevalence was higher among transgenders. While HIV testing is low among female sex workers (3.1%) and injecting drug users (5.2%), access to testing is even loweramong MSM (<1%). Existing HIV programs cover less than one-fifth of the MSM population with further gaps in prevention and treatment especially for third genders who are excluded from national strategies. In addition, national programs completely exclude male and transgender sex workers, focusing efforts only on female sex workers.

The epidemic of HIV among MSM and third genders in Nepal is driven by a number of important factors including lack of knowledge about HIV risk behavior, sexual networking with the general population, poor understanding of contextual factors and marginalization in a traditional society. Importantly, stigma and discrimination is widespread, and Nepal has a poor record respecting basic human rights of vulnerable sub-populations. Nepal’s ratification of several human rights treaties, including the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (CAT), the International Covenant on Civil and Political Rights (ICCPR), and the International Covenant on Economic Social and Cultural Rights (ICESCR), has not translated into concrete human rights protection for vulnerable groups. Finally, the decade-long Maoist-led insurgency against the government has further weakened social and physical infrastructure, led to increased restrictions on basic rights and freedoms in the broader population, disrupted civil society, and caused substantial and disruptive population flows, including rural to urban migration and emigration (mainly to India, Middle East, and Southeast Asia).

A framework to elucidate the interaction of societal, community, relationship and individual factors is helpful in understanding the likely risk determinants and causal pathways driving the HIV epidemic among MSM and third genders in Nepal. At the societal level, legal discrimination against MSM and third genders in Nepal exists through laws that prohibit “unnatural sex” and a discriminatory health system limits care-seeking behavior and excludes potential avenues for risk-reduction strategies. At the community level, the stigma associated with MSM and third genders and police torture for carrying condoms hinders HIV prevention strategies. Peer outreach workers are often harassed by police, limiting prevention programs from reaching the most vulnerable. At the relationship level, the pressure on MSM and third genders to marry and have children can lead to the propagation of the HIV epidemic among the general population. All these forces can lead to personal high-risk behavior and high rates of depression and anxiety at the individual level.

Results: To follow

Funded by the Center for Global Health