HIV trends, risk behaviours, social structural barriers and retention in HIV care among key populations in Nepal and the Asia-Pacific region

Abstract: Background: The HIV epidemic in the Asia-Pacific region is characterised by a number of concentrated, and in some geographical areas, growing epidemics, particularly among key populations [men who have sex with men (MSM), transgender (TG), female sex workers (FSW), and people who inject drugs (PWID)]. Some countries in the region have been particularly successful in reducing the incidence rate, but other countries in the region have experienced opposite scenarios. The coverage of antiretroviral treatment (ART) is still low in the region, ranging between 6-42%. Key populations in many Asia-Pacific countries also frequently suffer from discrimination and marginalisation, and their behaviours, often classified as illegal, further increase their already high vulnerability to HIV infection. HIV continues to spread predominantly through sexual transmission and can be linked to sexual risk behaviours, such as inconsistent condom use. More than 90% of all new HIV infections among young people in the Asia-Pacific region occur among young key populations belonging to either the MSM, TG, FSW or PWID group. The aim of this study was to understand HIV trends, social structural barriers, risk behaviours and retention in HIV care among key populations in 7 countries of the Asia-Pacific region, with a special focus on Nepal. Methods: This project utilised two main data sources: (a) baseline data from a prospective longitudinal study of community access to HIV treatment, care and support services (CAT-S) that involved 59 sites in 7 countries (Bangladesh, Indonesia, Lao People’s Democratic Republic, Nepal, Pakistan, Philippines, Vietnam). Between 1 October 2012 and 31 May 2013, a total of 7 843 people living with HIV (PLHIV) aged 18-50 years were recruited in CAT-S. (b) Nationwide surveillance survey data collected from key populations (PWID, MSM, TG, FSW, male labour migrants) across Nepal for over a decade. A total of 7 505 young (aged 16-24 years) key populations were recruited using two-stage cluster and respondent driven sampling from four epidemic zones over a 12-year period, 2001–2012. Results: We found a high prevalence of inconsistent condom use among PLHIV in the seven study countries: overall 40%, but varying from 17% in Lao People’s Democratic Republic to 60% in the Philippines, did not practice safe sex., This was associated with belonging to a key population (drug users, FSW or a refugee sub-population), poor HIV-treatment literacy and not receiving ART (Paper I). A high proportion of PLHIV (40-51%) presented late for HIV care, which delayed linkage to care. However, once PLHIV enrolled in care, retention in the various steps of the HIV care cascade including adherence to ART was satisfactory (Paper II). Findings based on surveillance survey data suggest that adverse micro-level social structural factors such as reduced condom-negotiation skills, economic vulnerability, inadequate social support, and experience of abuse, contribute to enhance the risk environment associated with unprotected sex among FSW in Nepal (Paper III). Our analyses also indicate that the presence of two or more adverse conditions in the physical, social, or economic environment of FSW, interacted to increase the risk of unprotected sex among Nepalese FSW (Paper III). However, the trend analysis suggests a sharp and consistent decline in HIV prevalence over the past decade in different epidemic zones among young key populations in Nepal, most likely due to a parallel increase in safe needle and syringe use and increased condom use (Paper IV). Conclusions: Non-use of condoms and late presentation for HIV care is still highly prevalent among PLHIV in the seven study countries. Different adverse conditions, so-called micro-level social structural factors such as physical factors (client refusal to pay after having sex), social factors (poor social support and poor condom negotiation skills) and economic level factors (unprotected sex to make more money) levels are associated with increased odds of HIV-related risk behaviours among Nepalese FSW. HIV prevalence and risk behaviours have declined among young key populations in Nepal, but to maintain this downward trend, the focus should be on addressing the burden of negative social structural factors (unprotected sex to boost income and poor social support).