Perceptions on violence against women and its impacts on mental health and response mechanisms among community-based stakeholders: a qualitative study from Nepal.

BACKGROUND: Violence against women (VAW) is a significant public health problem. With the emergence of the COVID-19 pandemic, the frequency and severity of VAW has escalated globally. Approximately one in four women in Nepal have been exposed to either physical, psychological, and/or sexual violence in their lifetime, with husbands or male partners being the perpetrators in most cases. VAW prevention has been under-researched in low- and middle-income countries, including Nepal. This study aims to explore the perspectives of local stakeholders, including healthcare providers and survivors of violence in Madhesh Province. The overarching goal is to provide insights for designing prevention and support programs that are acceptable to communities and cater to the needs of survivors. METHODS: An explorative qualitative study was conducted in Madhesh Province, southern Nepal. A total of 21 interviews, including 15 in-depth interviews (IDIs) with health care providers, three IDIs with women seeking general or maternal and child health services at health care centres, three key informant interviews with the local stakeholders working in the field of VAW, and one focus group discussion with violence survivors, were conducted in Nepali by trained field interviewers. Interviews were recorded, transcribed, translated into English, and analysed using content analysis. RESULTS: VAW, particularly physical violence, was a common experience in the study area. Sociocultural traditions such as dowry, child marriages and son preference were identifiable triggers for VAW, causing significant physical injuries and mental health problems, including suicide. Health care providers reported that violence survivors often hide their experiences of violence and do not seek any kind of help. Women feared that violence would increase in frequency and intensity if their perpetrators found out that they had disclosed their experiences of violence to health care providers. Local stakeholders emphasized the importance of engaging community leaders and garnering support from both women and men in interventions designed to reduce VAW and its impacts on mental health. CONCLUSIONS: Participants reported that verbal and physical violence is often perceived as a normal part of women's lives. Women should be made aware of available support services and empowered and supported to increase access and uptake of these services. Additionally, more individual-based counselling sessions that encourage women to escape violence and its mental health consequences while maintaining privacy and confidentiality are recommended.

Preferences for mHealth Intervention to Address Mental Health Challenges Among Men Who Have Sex With Men in Nepal: Qualitative Study.

BACKGROUND: Men who have sex with men (MSM) are disproportionately burdened by poor mental health. Despite the increasing burden, evidence-based interventions for MSM are largely nonexistent in Nepal. OBJECTIVE: This study explored mental health concerns, contributing factors, barriers to mental health care and support, and preferred interventions to improve access to and use of mental health support services among MSM in Nepal. METHODS: We conducted focus groups with MSM in Kathmandu, Nepal, in January 2023. In total, 28 participants took part in 5 focus group sessions. Participants discussed several topics related to the mental health issues they experienced, factors contributing to these issues, and their suggestions for potential interventions to address existing barriers. The discussions were recorded, transcribed, and analyzed using Dedoose (version 9.0.54; SocioCultural Research Consultants, LLC) software for thematic analysis. RESULTS: Participants reported substantial mental health problems, including anxiety, depression, suicidal ideation, and behaviors. Contributing factors included family rejection, isolation, bullying, stigma, discrimination, and fear of HIV and other sexually transmitted infections. Barriers to accessing services included cost, lack of lesbian, gay, bisexual, transgender, intersex, queer, and asexual (LGBTIQA+)-friendly providers, and the stigma associated with mental health and sexuality. Participants suggested a smartphone app with features such as a mental health screening tool, digital consultation, helpline number, directory of LGBTIQA+-friendly providers, mental health resources, and a discussion forum for peer support as potential solutions. Participants emphasized the importance of privacy and confidentiality to ensure mobile apps are safe and accessible. CONCLUSIONS: The findings of this study have potential transferability to other low-resource settings facing similar challenges. Intervention developers can use these findings to design tailored mobile apps to facilitate mental health care delivery and support for MSM and other marginalized groups.

Assessing the Nepalese health system's readiness to manage gender-based violence and deliver psychosocial counselling.

Violence against women (VAW), particularly intimate partner violence (IPV) or domestic violence, is a major public health issue, garnering more attention globally post-coronavirus disease 2019 (COVID-19) lockdown. Health providers often represent the first point of contact for IPV victims. Thus, health systems and health providers must be equipped to address survivors' physical, sexual and mental health care needs. However, there is a notable lack of evidence regarding such readiness in Nepal. This study, utilizing a concurrent triangulation design, evaluated the readiness of public health facilities in Nepal's Madhesh Province in managing VAW, focusing on providers' motivation to offer psychosocial counselling to survivors. A cross-sectional study was conducted across 11 hospitals and 17 primary health care centres, where 46 health care providers were interviewed in February-April 2022. The study employed the World Health Organization's tools for policy readiness and the Physician Readiness to Manage IPV Survey for data collection. Quantitative and qualitative data were collected via face-to-face interviews and analysed using descriptive and content analysis, respectively. Only around 28% of health facilities had trained their staff in the management of VAW. Two out of 11 hospitals had a psychiatrist, and a psychosocial counsellor was available in four hospitals and two out of 17 primary health care centres. Two-thirds of all health facilities had designated rooms for physical examinations, but only a minority had separate rooms for counselling. Though a few health facilities had guidelines for violence management, the implementation of these guidelines and the referral networks were notably weak. Hospitals with one-stop crisis management centres demonstrated readiness in VAW management. Health providers acknowledged the burden of IPV or domestic violence and expressed motivation to deliver psychosocial counselling, but many had limited knowledge. This barrier can only be resolved through appropriate training and investment in violence management skills at all tiers of the health system.

High Interest in the Use of mHealth Platform for HIV Prevention among Men Who Have Sex with Men in Nepal.

Mobile technology growth in Nepal offers promising opportunities for using mobile health (mHealth) interventions to facilitate HIV prevention efforts. However, little is known about access and utilization of communication technology and their willingness to use mHealth for HIV prevention services in Nepal. We conducted a cross-sectional respondent-driven sampling survey of 250 MSM in Kathmandu Valley of Nepal from October to December 2022. We collected information on participant characteristics, HIV risk-related behaviors, ownership, or access to and frequency of use of communication technology (phones, tablets, laptops, and computers), and willingness to use mHealth to access HIV prevention services. Descriptive, bivariate, and multivariate linear regression analyses were performed. Almost all participants had smartphones with the internet (231/250, 92.4%) and accessed the internet daily (219/250, 87.6%) on the smartphone (236/250, 94.4%). The median score for willingness to use mHealth for HIV prevention was 10 (IQR: 3 to 17). Willingness to use mHealth was higher among those participants with a high school or above education (ß = 0.223, p = < 0.001), had experienced violence (ß = 0.231, p = 0.006), and had moderate to severe depressive symptoms (ß = 0.223, p = < 0.001). However, monthly income above NPR 20,000 (USD 150) (ß= -0.153, p = 0.008), disclosure of their sexual orientation to anyone (ß= -0.159, p = < 0.007), and worry about being negatively judged by health care workers (ß= -0.136, p = 0.023) were less willing to use mHealth strategies. The findings from this study suggest that there is a high willingness for utilizing mHealth interventions for HIV prevention in MSM population who are at higher risk of HIV acquisition.

Prevalence of viral load suppression and acquired drug resistance among people living with HIV in Nepal: a nationally representative surveillance study.

OBJECTIVES: This is the first nationally representative study to estimate the prevalence of viral load (VL) suppression and acquired HIV drug resistance (ADR) among people living with HIV (PLHIV) in Nepal. METHODS: A cross-sectional study recruited 1418 PLHIV from 20 ART centres in Nepal, using a two-stage cluster design. Participants were eligible if they were HIV-positive individuals on ART for 9-15 months or at least 48 months. Plasma specimens were collected and tested for the quantification of HIV-1 RNA. Specimens with a VL ≥1000 copies/mL were further processed for sequencing of PR and RT genes of HIV-1. The sequences were then analysed to detect mutations causing HIV drug resistance. RESULTS: The prevalence of ADR was 3.7% (95% confidence interval [CI]: 1.8-7.6) and 3.0% (95% CI: 1.8-5.2) among PLHIV who received ART for 9-15 months and 48 months or more, respectively. The prevalence of VL suppression was 95.3% (95% CI: 91.7-97.4) among those on ART for 9-15 months, and 96.5% (95% CI: 94.7-97.7) among those on ART for at least 48 months. The prevalence of any detectable acquired resistance to antiretroviral drugs was 80.7% (95% CI: 58.6-92.5) among those on ART for 9-15 months with VL ≥1000 copies/mL and 81.6% (95% CI: 55.4-94.0) among those on ART for at least 48 months with VL ≥1000 copies/mL. CONCLUSION: This study suggests that improved accessibility to VL monitoring and timely assessment of drug resistance in routine HIV programs are crucial in Nepal to ensure access to HIV treatment for all in need.

The impact of border crossing and imprisonment on injection practices and risk of HIV and hepatitis C infection among men who inject drugs in Nepal.

BACKGROUND: In Nepal, personal drug use is criminalized and among people who inject drugs (PWID), the majority of whom are men, movement across the border with India for drug procurement and use is common. Using a risk environment approach, this study examined associations between border crossing and imprisonment with respect to HIV, HCV and injection risk behavior among men who inject drugs in Nepal. METHODS: This cross-sectional study analyzed data from 1345 participants from 14 districts across Nepal. Explanatory variables were prior imprisonment and past-month border crossing to procure or use drugs. We used multivariable logistic regression to evaluate associations between these variables and HIV, HCV, HIV/HCV co-infection and past-month injection risk behavior among PWID. RESULTS: Over half of participants reported prior imprisonment (34.6% prior to past year, 21.6% within past year) and Indo-Nepal border crossing in the past year to use or buy drugs (31.2% sometimes, 20.8% often); over one quarter of participants (29.6%) reported both. Imprisonment prior to the past year was associated with higher odds of all outcome variables: HIV (adjusted odds ratio (aOR) 2.44, 95% confidence interval (CI) 1.29-4.59), HCV (aOR 1.51, 95% CI 1.08-2.09), HIV/HCV co-infection (aOR 3.12, 95% CI 1.58-6.14) and injection risk behavior (aOR 1.64, 95% CI 1.20-2.25). Past-year border crossing to procure or use drugs was associated with HCV (aOR 2.06, 95% CI 1.42-2.98) and injection risk behavior (aOR 1.47, 95% CI 1.04-2.10), with larger effect sizes among PWID who reported both border crossing as well as history of imprisonment. CONCLUSION: Imprisonment and border crossing were associated with injection risk behavior and disease outcomes. These findings indicate a need to implement cross-border disease surveillance and harm reduction initiatives in the Indo-Nepal border region and in Nepali prisons.

Feasibility and Effectiveness of an Intervention to Reduce Intimate Partner Violence and Psychological Distress Among Women in Nepal: Protocol for the Domestic Violence Intervention (DeVI) Cluster-Randomized Trial.

BACKGROUND: Intimate partner violence (IPV) disproportionately affects people in low-and middle-income countries (LMICs), such as Nepal. Women experiencing IPV are at higher risk of developing depression, anxiety, and posttraumatic stress disorder. The shortage of trained frontline health care providers, coupled with stigma related to IPV and mental health disorders, fuels low service uptake among women experiencing IPV. The Domestic Violence Intervention (DeVI) combines the Problem Management Plus counseling program developed by the World Health Organization with a violence prevention component. OBJECTIVE: This study aims to implement and evaluate the feasibility, acceptability, and effectiveness of DeVI in addressing psychological distress and enabling the secondary prevention of violence for women experiencing IPV. METHODS: A parallel cluster-randomized trial will be conducted across 8 districts in Madhesh Province in Nepal, involving 24 health care facilities. The study will include women aged 18-49 years who are either nonpregnant or in their first trimester, have experienced IPV within the past 12 months, have a 12-item General Health Questionnaire (GHQ-12) score of 3 or more (indicating current mental health issues), and have lived with their husbands or in-laws for at least 6 months. A total sample size of 912 was estimated at 80% power and α<.05 statistical significance level to detect a 15% absolute risk reduction in the IPV frequency and a 50% reduction in the GHQ-12 score in the intervention arm. The health care facilities will be randomly assigned to either the intervention or the control arm in a 1:1 ratio. Women visiting the health care facilities in the intervention and control arms will be recruited into the respective arms. In total, 38 participants from each health care facility will be included in the trial to meet the desired sample size. Eligible participants allocated to either arm will be assessed at baseline and follow-up visits after 6, 17, and 52 weeks after baseline. RESULTS: This study received funding in 2019. As of December 29, 2022, over 50% of eligible women had been recruited from both intervention and control sites. In total, 269 eligible women have been enrolled in the intervention arm and 309 eligible women in the control arm. The trial is currently in the recruitment phase. Data collection is expected to be completed by December 2023, after which data analysis will begin. CONCLUSIONS: If the intervention proves effective, it will provide evidence of how nonspecialist mental health care providers can address the harmful effects of IPV in resource-constrained settings with a high burden of IPV, such as Nepal. The study findings could also contribute evidence for integrating similar services into routine health programs in LMICs to prevent IPV and manage mental health problems among women experiencing IPV. TRIAL REGISTRATION: ClinicalTrials.gov NCT05426863; https://clinicaltrials.gov/ct2/show/NCT05426863. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/45917.

The burden of mental disorders, substance use disorders and self-harm among young people in Europe, 1990-2019: Findings from the Global Burden of Disease Study 2019.

Background: Mental health is a public health issue for European young people, with great heterogeneity in resource allocation. Representative population-based studies are needed. The Global Burden of Disease (GBD) Study 2019 provides internationally comparable information on trends in the health status of populations and changes in the leading causes of disease burden over time. Methods: Prevalence, incidence, Years Lived with Disability (YLDs) and Years of Life Lost (YLLs) from mental disorders (MDs), substance use disorders (SUDs) and self-harm were estimated for young people aged 10-24 years in 31 European countries. Rates per 100,000 population, percentage changes in 1990-2019, 95% Uncertainty Intervals (UIs), and correlations with Sociodemographic Index (SDI), were estimated. Findings: In 2019, rates per 100,000 population were 16,983 (95% UI 12,823 - 21,630) for MDs, 3,891 (3,020 - 4,905) for SUDs, and 89·1 (63·8 - 123·1) for self-harm. In terms of disability, anxiety contributed to 647·3 (432-912·3) YLDs, while in terms of premature death, self-harm contributed to 319·6 (248·9-412·8) YLLs, per 100,000 population. Over the 30 years studied, YLDs increased in eating disorders (14·9%;9·4-20·1) and drug use disorders (16·9%;8·9-26·3), and decreased in idiopathic developmental intellectual disability (-29·1%;23·8-38·5). YLLs decreased in self-harm (-27·9%;38·3-18·7). Variations were found by sex, age-group and country. The burden of SUDs and self-harm was higher in countries with lower SDI, MDs were associated with SUDs. Interpretation: Mental health conditions represent an important burden among young people living in Europe. National policies should strengthen mental health, with a specific focus on young people. Funding: The Bill and Melinda Gates Foundation.

Prevalence of HIV, Hepatitis C and its related risk behaviours among women who inject drugs in the Kathmandu Valley, Nepal: a cross-sectional study.

BACKGROUND: People who inject drugs (PWID) are at great risk of HIV and Hepatitis C Virus (HCV). In order to properly design interventions and develop programmes for women who inject drugs, this study assessed the prevalence of HIV, Hepatitis B, Hepatitis C, and syphilis and its risk behaviours among women who inject drugs in the Kathmandu Valley, Nepal. METHODS: Through modified network sampling in three districts in the Kathmandu Valley, Nepal, this cross-sectional study enrolled a total of 160 women who inject drugs. Participants' serum samples were tested for HIV, HCV, Hepatitis B virus (HBV) and syphilis and risk behaviours were assessed through a structured questionnaire. Primary outcome variables were HIV, HCV, HBV and syphilis prevalence, and secondary outcome variables were sharing needles in the past month and using condom in last sexual intercourse. Stepwise logistic regression was used to determine micro- and macroenvironmental factors associated with secondary outcomes. RESULTS: The prevalence of HIV, HCV, and HBV was 8.8%, 21.3%, and 1.9%, respectively. HIV-HCV co-infection rate was 5.6%. Fifteen percent of women who inject drugs reported transactional sex for drugs or money. One in four women who inject drugs (27.5%) reported that they were imprisoned or detained for drug related reasons. In multivariable analysis, women living with HIV who inject drugs were almost four times more likely to use a previously used needle/syringe than women who inject drugs who were HIV negative (aOR: 4.2 CI: 1.1-15.9, p = 0.03), but were almost four times more likely to use a condom during sexual intercourse (aOR: 3.5 CI: 1.1-28.9, p = 0.03). Enrolment in family planning was the main determinant for using condoms in last sexual intercourse (aOR 4.9 CI: 1.6-16.7, p = 0.006). Participants with access to HIV test and counselling (HTC) services were less likely to share needles (aOR: 0.3, 95% CI: 0.1-0.8, p = 0.01). CONCLUSION: Prevalence of HIV and HCV is high among women who inject drugs in Kathmandu valley of Nepal. Women who inject drugs enrolled in national programmes such as family planning and HTC were positively associated with condom use, and less likely to share needles.

Social and structural factors associated with depression and suicidality among men who have sex with men and transgender women in Nepal.

INTRODUCTION: The prevalence of depression and suicidality is high among men who have sex with men (MSM) and transgender women (TGW) worldwide. Stigma and discrimination are likely contributing factors. More research is needed in low-income, non-English speaking countries to assess the effects of social and structural factors on depression and suicidality among MSM and TGW. METHODS: Nepalese MSM and TGW (n = 340) were recruited using a respondent-driven sampling design and filled out a survey questionnaire. The outcomes were depression and suicidality. Data was analyzed using bivariate and multivariable logistic regression. RESULTS: More than half of the participants (59%) suffered from depression. Severe depression was more common among TGW compared to MSM (41 and 20%, respectively). When it comes to suicidality, TGW had higher lifetime prevalence of suicidal thoughts compared to MSM (32 and 5%, respectively). Depression was positively associated with sex work both for MSM (AOR: 7.9; 95% CI 3.4-18.2) and TGW (AOR: 6.5; 95% CI: 2.3-18.2). MSM who were evicted by family had high odds of suicidal thoughts (AOR: 6.2; 95% CI: 1.3-28.8). For TGW, suicidality was associated with being cheated and threatened (AOR: 3.9; 95% CI: 1.2-12.5) and having forced to marry a female (AOR: 2.2; 95% CI 1.1-5.1). CONCLUSIONS: Nepalese MSM and TGW suffer from a high degree of mental and psychosocial health issues. Future studies should focus on intervention research and on collecting data from a larger variety of gender and sexual minorities.

Trends and determinants of HIV transmission among men who inject drugs in the Pokhara Valley, Nepal: analysis of cross-sectional studies.

BACKGROUND: HIV is a major public health issue around the world, especially in developing countries. Although the overall prevalence of HIV in Nepal is relatively low, there are specific sub-populations where the prevalence is far higher than the national average. One of these sub-groups is male people who inject drugs (male PWIDs). In order to understand the reasons for the differences in prevalence, a series of socio-demographic, behavioural and knowledge-based risk factors need to be assessed. METHODS: The study used a series of 7 cross-sectional survey datasets from Pokhara (Nepal), collected between 2003 and 2017 (N = 2235) to investigate trends in HIV prevalence among male PWIDs by socio-demographic and behavioural and knowledge-based risk factors. A series of logistic regression models were conducted to investigate the association between study factors and HIV. RESULTS: HIV prevalence decreased from the levels seen in 2003 (22.0%) and 2005 (21.7%), with the lowest prevalence recorded in 2015 (2.6%), however prevalence has increased in the most recent period (4.9%). A lower risk of HIV was associated with younger age (<=24 years compared to > 24 years, OR = 0.17, 95% CI = 0.10-0.31), being married (OR = 1.91, 95% CI = 1.25-3.02) and shorter duration of drug use (<=4 years compared to > 4 years, OR = 0.16, 95% CI = 0.09-0.29). A higher risk of HIV was associated with low (compared to secondary or higher) education level (OR = 2.76, 95% CI = 1.75-4.36), a lack of addiction treatment (OR = 2.59, 95% CI = 1.64-4.08), and recent use of unsterilized injection equipment (OR = 2.22, 95% CI = 1.20-4.11). CONCLUSION: The prevalence of HIV in male PWIDs in Pokhara has been variable, but overall has reduced in recent years to 2.6% before increasing in 2017 to 4.9%. The main determinants which increase the risk of HIV among male PWIDs in Pokhara are low education level, a lack of treatment for drug addiction and the recent use of unsterilised equipment. Each of these indicate the need to improve addiction treatment and education programs for intra-venous drug use to aid this key population in avoiding risk-taking behaviours.

Prevalence of HIV, syphilis, and assessment of the social and structural determinants of sexual risk behaviour and health service utilisation among MSM and transgender women in Terai highway districts of Nepal: findings based on an integrated biological and behavioural surveillance survey using respondent driven sampling.

BACKGROUND: Men who have sex with men (MSM) and transgender people are disproportionately affected by HIV and sexually transmitted infections. MSM and transgender people in Nepal experience considerable discrimination and marginalisation, they are subject to abuse from legal authorities and suffer from mental health issues. These social and structural factors can lead to increased sexual risk behaviour, barriers to accessing health care and result in adverse health outcomes. This study aims to assess the prevalence of HIV and syphilis, and how individual and socio-structural factors influence sexual risk behaviour and health care service uptake, among MSM and transgender women in the Terai highway districts of Nepal. METHODS: A cross-sectional survey was conducted in June 2016 in eight Terai highway districts of Nepal, recruiting 340 MSM and transgender women through respondent driven sampling. The primary outcome variables were HIV and syphilis prevalence. The secondary outcome variables were sexual risk behaviour and health care service uptake. Logistic regression models were used to assess the individual and socio-structural determinants of sexual risk behaviour and health care service uptake. RESULTS: The prevalence of HIV among MSM was 5%, whereas it was 13% in transgender women. The prevalence of active syphilis was 4% in MSM and 11% among transgender women. Among transgender women, 76% were involved in sex work, and 51% had experienced discrimination in one or more settings. In multivariable analysis, having visited an outreach centre was positively associated with condom use in the last sexual encounter among both MSM (AOR: 5.37, 95% CI: 2.42-11.94, p < 0.001) and transgender women (AOR: 2.37, 95% CI: 1.12-5.02, p = 0.025). Moreover, transgender women who reported being open towards family about sexual identity/behaviour were 2.4 more likely to have visited an outreach centre (AOR: 2.40, 95% CI: 1.04-5.57, p = 0.041). CONCLUSIONS: The high prevalence of HIV and syphilis, as well as indicators of marginalisation and discrimination among transgender women, highlights the increased burden transgender women in Nepal are facing and the need for tailored interventions. Moreover, since health care service uptake is an important factor in determining sexual risk behaviour among MSM and transgender women in Nepal, outreach services should be scaled up.

Effectiveness of interventions for changing HIV related risk behaviours among key populations in low-income setting: A Meta-Analysis, 2001-2016.

The aim of this review was to conduct a meta-analysis to assess the effectiveness of behavioural interventions to reduce HIV-related risk behaviours among key populations: people who inject drugs, female sex workers, men who have sex with men and transgender in Nepal over the last two decades. Using four electronic databases, we performed a systematic search of the literature on HIV interventions implemented in Nepal and published from January 2001 to December 2016. In addition, grey literature was also scrutinised for potential articles. The search focussed specifically on behavioural interventions (peer education and HIV testing services) targeted for key populations. Random-effects models were used to calculate the pooled odds ratio for dichotomous outcomes (condom use in last sex or unsafe injection practices), pooled HIV prevalence and subgroup analyses by age groups and epidemic zones in Nepal. Forty-three studies with 15,642 participants were included (people who inject drugs: 7105; men who have sex with men and transgender: 2637; female sex workers: 5900). Pooled prevalence showed a higher occurrence of HIV among people who inject drugs (12%) followed by men who have sex with men/transgender (5%) and female sex workers (2%) respectively. There was a significant increase in the odds of condom use among female sex workers, men who have sex with men and transgender who received peer education interventions in both informal and formal setting compared to those who did not. Similarly, the odds of condom use among female sex workers, men who have sex with men and transgender improved significantly among those who received HIV counselling and testing services as compared to those who did not use such services. Subgroup analyses also verified the effectiveness of these interventions for both young and adult key populations and across all three epidemic zones. However, none of the included interventions were found to be effective for reducing unsafe injection practices among people who inject drugs. HIV prevention interventions in Nepal have effectively reduced risky behaviours among female sex workers, men who have sex with men and transgender over the last two decades but not among people who inject drugs. This calls for continued implementation of existing efforts as well as for new interventions adapted to the needs of people who inject drugs.

Stigma reduction interventions in people living with HIV to improve health-related quality of life.

As the UNAIDS 90-90-90 targets for people living with HIV are increasingly being reached in many contexts, health-related quality of life, the so-called fourth 90, warrants special attention. HIV-related stigma and discrimination are major barriers for overall health-related quality of life despite impressive clinical and virological improvements in HIV care. There is a scarcity of well designed intervention studies that document stigma reduction in people living with HIV and few studies that specifically assess the effect of stigma on health-related quality of life. Further, few interventions target discrimination from providers outside of HIV-specific care or involve people living with HIV in both the design and implementation. Lastly, evidence on methods to reduce stigma in several underepresented key populations and geographical regions is insufficient and research on intersectional stigma (ie, the convergence of multiple stigmatised identities) needs further attention.

Condom use behaviour among people living with HIV: a seven-country community-based participatory research in the Asia-Pacific region.

OBJECTIVES: We examined the prevalence of inconsistent condom use and its correlates among people living with HIV (PLHIV) in the Asia-Pacific region. METHODS: Between 1 October 2012 and 31 May 2013, a total of 7843 PLHIV aged 18-50 years were recruited using targeted and venue-based sampling in Bangladesh, Indonesia, Lao People's Democratic Republic (PDR), Nepal, Pakistan, Philippines and Vietnam. Logistic regression was used to explore the association between condom use behaviour and demographics, social support, stigma and discrimination and various health-related variables. RESULTS: Overall, 43% of 3827 PLHIV practised inconsistent condom use at sexual intercourse with their regular partner. An even higher proportion, 46% of 2044 PLHIV admitted that they practised unprotected sex with a casual partner. Participants from Lao PDR reported the lowest prevalence of inconsistent condom use for both regular and casual partners, while participants from the Philippines had the highest risk behaviour. Inconsistent condom use was significantly associated with belonging to a key population (drug user, sex worker or refugee subpopulation), not knowing that condoms are still needed if both partners are HIV positive, having a regular partner whose HIV status was either positive or unknown, having experienced physical assault and not receiving antiretroviral treatment. CONCLUSIONS: This large seven-country study highlights a high prevalence of inconsistent condom use among PLHIV in the Asia-Pacific region. In addition to knowledge-imparting interventions, the adoption and expansion of the 'Test and Treat' strategy could help to maximise the prevention benefits of antiretroviral treatment.

Why don't key populations access HIV testing and counselling centres in Nepal? Findings based on national surveillance survey.

OBJECTIVES: To assess the demographic, behavioural, psychosocial and structural factors associated with non-utilisation of HIV testing and counselling (HTC) services by female sex workers (FSWs) and men who have sex with men/transgender (MSM/TG). METHODS: This study involved a cross-sectional design. We used the national surveillance survey data of 2012, which included 610 FSWs and 400 MSM/TG recruited randomly from 22 and three districts of Nepal, respectively. Adjusted prevalence ratio (aPR) and 95% confidence interval (CI) using modified Poisson regression was used to assess and infer the association between outcome (non-utilisation of HTC in last year) and independent variables. RESULTS: Non-utilisation of HTC in the last year was 54% for FSWs and 55% for MSM/TG. The significant factors for non-utilisation of HTC among FSWs were depression (aPR=1.4 (95% CI 1.1 to 1.6)), injectable drug abuse (ever) (aPR=1.4 (95% CI 1.1 to 1.8)), participation (ever) in HIV awareness programmes (aPR=1.2 (95% CI 1.0 to 1.4)), experience of forced sex in previous year (aPR=1.1 (95% CI 1.0 to 1.3)) and absence of dependents in the family (aPR=1.1 (95% CI 1.0 to 1.3)). Non-utilisation of HTC among MSM/TG had significant association with age 16-19 years (aPR=1.4 (95% CI 1.1 to 1.7)), non-condom use (aPR=1.2 (95% CI 1.0 to 1.4)), participation (ever) in HIV awareness programmes (aPR=1.6 (95% CI 1.3 to 2.0)), physical assault in previous year (aPR=1.8 (95% CI 1.0 to 3.1)), experience of forced sex in previous year (aPR=0.5 (95% CI 0.3 to 0.9)). CONCLUSION: Although limited by cross-sectional design, we found many programmatically relevant findings. Creative strategies should be envisaged for effective behavioural change communication to improve access to HIV testing. Psychosocial and structural interventions should be integrated with HIV prevention programmes to support key populations in accessing HIV testing.

Facilitators and barriers for retention in HIV care between testing and treatment in Asia-A study in Bangladesh, Indonesia, Lao, Nepal, Pakistan, Philippines and Vietnam.

INTRODUCTION: The need for efficient retention in HIV care is more evident than ever because of the expansion of earlier ART initiation and the shift towards 'Test and Treat'. This study assesses factors affecting participation in the HIV care cascade among people living with HIV (PLHIV) in the Asia-Pacific Region. METHODS: A total of 7843 PLHIV aged 18-50 years were recruited using targeted and venue-based sampling between October 1, 2012, and May 31, 2013, across 59 sites in 7 countries (Bangladesh, Indonesia, Lao People's Democratic Republic (Lao PDR), Nepal, Pakistan, Philippines and Vietnam). Statistically significant associations between demographic and health system determinants, and various steps in the HIV care cascade were computed using a generalized structural equation model. RESULTS: A high proportion of PLHIV (40-51%) presented late for HIV care and delayed linkage to care in all seven countries. However, once PLHIV enrolled in care, retention in the various steps of the care cascade including adherence to antiretroviral treatment (ART) was satisfactory. The proportion still engaged in HIV care at 36 months post HIV diagnosis, varied from 78% in Nepal to >90% in Lao PDR. Similarly, the proportion of ART initiation who also were adherent to ART ranged from 91% in Bangladesh to >95% in Philippines/ Vietnam and from 70% in Lao PDR to 89% in the Philippines respectively. The following factors enhanced the likelihood of ART initiation and high adherence to HIV care and ART: good client-provider communication, high HIV treatment literacy, a referral from a health worker and TB/HIV co-infection. The following barriers were identified: young age, sex work, imprisonment, transgender identity, illiteracy, rural residence, alcohol/ injecting drug use, perceived poor health status, lack of health insurance, fear of confidentiality breach, self-referral for HIV testing, and public hospital as the place of HIV diagnosis. CONCLUSIONS: HIV programme planners should ensure easy access to HIV testing and earlier linkage to HIV care among PLHIV. In addition, multiple socio-economic and health systems barriers need to be addressed along the HIV care cascade to reach the UNAIDS 90-90-90 target in the Asia-Pacific region.

HIV decline associated with changes in risk behaviours among young key populations in Nepal: analysis of population-based HIV prevalence surveys between 2001 and 2012.

We assessed changes in HIV prevalence and risk behaviours among young key populations in Nepal. A total of 7505 participants (aged 16-24 years) from key populations who were at increased risk of HIV infection (2767 people who inject drugs (PWID); 852 men who have sex with men/transgender (MSM/TG); 2851 female sex workers (FSW) and 1035 male labour migrants) were recruited randomly over a 12-year period, 2001-2012. Local epidemic zones of Nepal (Kathmandu valley, Pokhara valley, Terai Highway and West to Far West hills) were analysed separately. We found a very strong and consistent decline in HIV prevalence over the past decade in different epidemic zones among PWID and MSM/TG in Kathmandu, the capital city, most likely due to a parallel increase in safe needle and syringe use and increased condom use. A decrease in HIV prevalence in 22 Terai highway districts, sharing an open border with India, was also consistent with increased condom use among FSW. Among male labour migrants, HIV prevalence was low throughout the period in the West to Far West hilly regions. Condom use by migrant workers involved with FSW abroad increased while their condom use with Nepalese FSW declined. Other risk determinants such as mean age at starting first injection, injection frequency, place of commercial sex solicitation, their mean age when leaving to work abroad did not change consistently across epidemic zones among the young key populations under study. In Nepal, the decline in HIV prevalence over the past decade was remarkably significant and consistent with an increase in condom use and safer use of clean needles and syringes. However, diverging trends in risk behaviours across local epidemic zones of Nepal suggest a varying degree of implementation of national HIV prevention policies. This calls for continued preventive efforts as well as surveillance to sustain the observed downward trend.

Perceived Discrimination Is an Independent Risk Factor for Suicidal Ideation among Sexual and Gender Minorities in Nepal.

Sexual and gender minorities experience an elevated burden of suicidality compared with the general population. Still, little is known about that burden and the factors generating it in the context of low- and middle-income countries. The present study assessed the prevalence of suicidal ideation, planned suicide, and attempted suicide among men who have sex with men (MSM) and transgender people (TG) in Nepal, and examined the association of perceived discrimination on the basis of sexual orientation with suicidal ideation and with attempted suicide. Data were obtained from a surveillance survey among MSM and TG in Nepal in 2012. A sample of 400 MSM and TG, recruited using respondent-driven sampling, completed a structured face-to-face interview. Throughout their lifetime, 26.8% of the participants had experienced suicidal ideation, 12.0% had made a suicide plan, and 9.0% had attempted suicide. In particular, more TG than MSM had experienced suicidal ideation (39.8% vs. 21.3%), had made a suicide plan (19.5% vs. 8.9%), and had attempted suicide (15.3% vs. 6.4%). Overall, the odds of having experienced suicidal ideation was significantly higher among the 38.3% of participants who had perceived discrimination based on their sexual orientation (AOR: 3.17; 95% CI: 1.83-5.48). Moreover, the odds of suicidal ideation was significantly higher as the extent of perceived discrimination increased (AOR: 1.35; 95% CI: 1.15-1.60). However, the odds of attempted suicide was not significantly associated with perceived discrimination (AOR: 1.40; 95% CI: 0.62-3.15). The findings highlight perceived discrimination as an independent risk factor for suicidal ideation. Future suicide prevention programs should target sexual and gender minorities and include elements focusing on discrimination.

Micro-level social and structural factors act synergistically to increase HIV risk among Nepalese female sex workers.

OBJECTIVES: Sex workers face stigma, discrimination, and violence across the globe and are almost 14 times more likely to be HIV-infected than other women in low- and middle-income countries. In Asia, condom campaigns at brothels have been effective in some settings, but for preventive interventions to be sustainable, it is important to understand micro-level social and structural factors that influence sexual behaviours of sex workers. This study assessed the syndemic effects of micro-level social and structural factors of unprotected sex and the prevalence of HIV among female sex workers (FSWs) in Nepal. METHODS: This quantitative study included 610 FSWs who were recruited using two-stage cluster sampling from September to November 2012 in 22 Terai Highway districts of Nepal. Rapid HIV tests and face-to-face interviews were conducted to collect biological and behavioural information. A count of physical (sexual violence and other undesirable events), social (poor social support and condom negotiation skills), and economic (unprotected sex to make more money) factors that operate at the micro-level was calculated to test the additive relationship to unprotected sex. RESULTS: The HIV prevalence was 1%; this is presumably representative, with a large sample of FSWs in Nepal. The prevalence of unprotected sex with clients was high (24%). For each additional adverse physical, social, and economic condition, the probability of non-use of condoms with clients increased substantially: one problem = 12% (p<0.005), two problems = 19% (p<0.001), and three to five problems = 38% (p<0.001). CONCLUSIONS: Interactions between two or more adverse conditions linked to physical, social, and economic environments increased the risk of unprotected sex among Nepalese FSWs.