The Use of Female Sex Workers Among Men in Nepal: Prevalence, STIs/HIV-Related Risk Behaviors, and Gender Ideology

Heterosexual sex involving female sex workers (FSWs) is widely documented for its role in facilitating the spread of sexually transmitted infections (STIs)/HIV. Critical to such studies, and increasingly considered essential to HIV prevention efforts, is the gender constructs and power dynamics within relationships. However, little efforts have been made, which focus on male clients of FSWs, particularly on the relationship between gender ideologies and men’s sexual contact with FSWs, within the Nepali context. 

The present study aims to fill this critical gap by assessing the prevalence of use of FSWs and its association with STIs/HIV-related risk behaviors and gender ideologies among Nepali men. We used data from the nationally representative Nepal Demographic Health Survey (NDHS) 2011. For the purpose of analyses, we included a sample of 4,121 men, aged 15–49 years. During data analyses, we used multivariate logistic regression models, adjusted for the following variables: age, region, residence, religion, educational level, wealth index, employment status, and cigarette smoking status. 

Of the total sample, approximately 5% reported the use of FSWs in their lifetime. In regression models, men who had sex with FSWs were more likely to report a history of STIs, not using condom all the time, more than one sexual partner, and have had early sexual debut. Respondents reporting the endorsement of violence against wives and male sexual entitlement were significantly more likely to report sexual contact with FSWs. 

Our findings highlight the need to develop and implement specifically tailored interventions toward male clients of FSWs, with a particular emphasis on promoting equitable gender roles and beliefs.

Full article at:    http://goo.gl/e97o7T

By: Roman Shrestha,^1,2 Pramila Karki,^2,3 and Michael Copenhaver^2,3

¹Department of Community Medicine and Health Care, University of Connecticut Health Center, Farmington, CT, USA

²Institute for Collaboration on Health, Intervention, and Policy, University of Connecticut, Storrs, CT, USA

³Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USA

Prim Prev Insights. Author manuscript; available in PMC 2016 Jun 27.

Published in final edited form as:

Prim Prev Insights. 2016; 6: 11–17.

Published online 2016 Jun 9. doi:  10.4137/PPRI.S39664

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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 it is important to understand micro-level social and structural factors that influence sexual behaviors of sex workers to be sustainable. This study assesses the syndemic effects of micro-level social and structural factors of unprotected sex and the prevalence of HIV among female sex workers in Nepal.

METHODS:

This quantitative study included 610 female sex workers that 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 behavioral 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% and this is presumably representative with a large sample of female sex workers in Nepal. The prevalence of unprotected sex with client was high (24%). For each additional adverse physical, social and economic condition, the probability of non-use of condoms with clients increased substantially: 1 problem=12%, p-value 0.005; 2 problems=19%, p-value <0.001; 3-5 problems= 38%, p-value <0.001.

CONCLUSIONS:

Interactions between two or more adverse conditions linked to physical, social and economic environment increased the risk of unprotected sex among Nepalese female sex workers.

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By:  Deuba K¹, Anderson S², Ekström AM³, Pandey SR⁴, Shrestha R⁵, Karki DK⁶, Marrone G³.

¹Public Health and Environment Research Center, Kathmandu, Nepal; Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden. Electronic address: deuba4k@gmail.com.

²Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.

³Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden.

⁴FHI360, Kathmandu, Nepal.

⁵Centre for International Health, University of Bergen, Bergen, Norway.

⁶Department of Public Health, Nobel College, Pokhara University, Kathmandu, Nepal.

Int J Infect Dis. 2016 Jun 13. pii: S1201-9712(16)31091-8. doi: 10.1016/j.ijid.2016.06.007. [Epub ahead of print]

  

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‘We are looked down upon and rejected socially’: A qualitative study on the experiences of trafficking survivors in Nepal

Background

The successful reintegration of sexual trafficking survivors into Nepalese society is challenging. This paper aims to explore the trafficking process, abuses faced during sexual slavery,and the challenges faced by women and girl survivors for successful reintegration.

Method

This exploratory study used qualitative methods to identify that poverty, illiteracy, lack of opportunities, and varied social stigma initiate the victimization process, and continuity of this vicious circle increases the risk for (re)entrapment.

Result

The reasons for sexual trafficking have also become the reasons for restricting survivors from opportunities for growth and mainstreaming.

Conclusion

Non-existent support systems, detachment from familial ties, being outcast by society, and an uncertain livelihood make reintegration difficult for survivors.

...Period of sexual slavery

The lives of the survivors during sexual slavery at the brothels speak of severe abuse. Arriving at a new place, without any acquaintances, and being subjected to continuous sexual slavery broke down the women. It was noted that the repeated physical violence and unwilling monotony of being just an object of sexual gratification caused the development of sudden suicidal tendencies in most of the trafficked survivors.

I landed in Hong Kong in the evening and was immediately taken to a hotel. After reaching the hotel, my passport was seized and then I was told that I had been sold for prostitution. At times, I used to hide in the warehouse filled with shoes and cover myself with the boxes. I felt that committing suicide was better than selling my body.

The survivors are cut off from the outside world and forced to live in conditions similar to a prison. The captors, on the other hand, use all kinds of methods to continue the enslavement of the trafficked; any documents of identification and money remaining to the survivors were immediately seized, and their movements were always monitored and restricted.

For three months, I didn't know that I had already been sold. There were almost seventy women from different countries in the building where I was kept. For three months, I kept nursing four to five children and learning the language. At the end of the three months, I was shifted to another room but in the same building. Since then, I had to offer sexual services to six to seven men during a day. After exactly a week, I thought of killing myself rather than living a life in hell. The living room of the house was ornamented with spears and swords; I managed to grab a spear and was determined to kill myself by plunging a spear in the electric circuit box. I remember waking up at the hospital with bandages below my waist. I stayed in the hospital for a month receiving treatments for my injuries and burns. After being discharged from the hospital, I was taken to the same house and kept under even stronger captivity on the twenty-fifth floor. I decided to escape using a rope made out of curtains, bedsheets, wire and quilt covers. I managed to reach the ground but my hands, knees, and legs were hurt badly and I was bleeding profusely. I walked into the Nepalese embassy, bleeding heavily with just a cloth wrapped around my body.

The survivors were subjected to severe inhumane practices. The consequence of continued physical abuse and repeated abortions also increase health risks. The survivors have to remain at the mercy of their captors if they develop any known symptoms of diseases, and spending money for health checkups does not fall in the priority list for these captors.

After reaching Lebanon, my passport was immediately seized and I started living as a prisoner in a big house. Later on, I realized that I was in a house where I had to sexually serve the owner and guests visiting the house. I found out that I had been sold for $1000. I felt like killing myself when I had to sleep with the drunken Arab men, but the constant thought of my child back home stopped me from committing suicide. I got pregnant twice and both times I was taken to a hospital for abortions. Later on, I was sent back to Nepal after two years with nothing but a developing child in my womb...

Full article at:   http://goo.gl/wqvaio

By:   Pranab Dahal,1,* Sunil Kumar Joshi,2 and Katarina Swahnberg1

¹Department of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden

²Department of Community Medicine, Kathmandu Medical College, Kathmandu, Nepal

^*Correspondence to: Pranab Dahal, Department of Health and Caring Sciences, Linnaeus University, SE-391 82 Kalmar, Sweden, Email:es.unl@lahad.banarp

Responsible Editor: Isabel Goicolea, Umeå University, Sweden.

 

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Sexual Relationships in Last 12 months among Men Who Have Sex with Men in Nepal

Background

Men who have sex with men (MSM) are marginalized, hidden, underserved and at high risk for HIV in Nepal. We examined the association between MSM sub-populations, psychosocial health problems and support, access to prevention and non-use of condoms.

Methods

Between September-November of 2010, a cross-sectional survey on HIV-related risk behavior was performed across Nepal through snowball sampling facilitated by non-governmental organizations, recruiting 339 MSM, age 15 or older. The primary outcomes were: (a) non-use of condoms at least once in last three anal sex encounters with men and (b) non-use of condoms with women in the last encounter. The secondary outcome was participation in HIV prevention interventions in the past year.

Results

Among the 339 MSM interviewed, 78% did not use condoms at their last anal sex with another man, 35% did not use condoms in their last sex with a woman, 70% had experienced violence in the last 12 months, 61% were experiencing depression and 47% had thought of committing suicide. After adjustment for age, religion, marital status, and MSM subpopulations (bisexual, ta, meti, gay), non-use of condoms at last anal sex with a man was significantly associated with non-participation in HIV interventions, experience of physical and sexual violence, depression, repeated suicidal thoughts, small social support network and being dissatisfied with social support. Depression was marginally associated with non-use of condoms with women. The findings suggest that among MSM who reported non-use of condoms at last anal sex, the ta subgroup and those lacking family acceptance were the least likely to have participated in any preventive interventions.

Conclusions

MSM in Nepal have a prevalence of psychosocial health problems in turn associated with high risk behavior for HIV. Future HIV prevention efforts targeting MSM in Nepal should cover all MSM subpopulations and prioritize psychosocial health interventions.

Full article at:  http://goo.gl/0Gchu8

By:   Keshab Deuba,1,* Anna Mia Ekström,2,3 Rachana Shrestha,4 George Ionita,5 Laxmi Bhatta,4 and Deepak Kumar Karki6

¹Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden

²Division of Global Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden

³Department of Infectious Diseases, Huddinge, Karolinska University Hospital, Stockholm, Sweden

⁴Nobel College, Pokhara University, Kathmandu, Nepal

⁵United Nations Development Programme (UNDP), Kathmandu, Nepal

⁶National Centre for AIDS and STD Control, Kathmandu, Nepal

University of Washington, United States of America

* E-mail: moc.liamg@k4abued

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HIV/AIDS: A Persistent Health Issue for Women and Children in Mid and Far Western Nepal

This article reviews the effect of male migration on the spread of HIV infections in mid and far-western Nepal. It explains the link between male mobility and HIV in women and children. Materials were collected by a systematic search of the databases and the websites of national and international agencies. HIV infection amongst male migrants was found to be high. 

Their risk behaviors such as unprotected sex with multiple partners and sex workers increase the risk of HIV infection. Substance abuse, loneliness, separation from families, peer pressure, long working hours and poor living conditions are factors that promote unsafe sex. Literacy and awareness about HIV is a key measure to decrease the prevalence of the disease and reduce social stigma among people affected. 

HIV is a major public health issue especially in Nepal with migration playing a major role in its spread. Negligence to sexual health and lack of comprehensive knowledge on the disease among male migrants are the major obstacles that have exacerbated the disease. 

There is a need for further research on the existing HIV cases affecting women and children of these two regions to get a clear picture of the gravity of the disease.

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By:  Awasthi KR1, Adefemi K1, Tamrakar M2.

• 1School of Public Health Faculty of Health Sciences Curtin University, Bentley 6102, WA.
• 2Department of Dentistry Kathmandu University School of Medical Sciences Dhulikhel, Kavre. 

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HIV-Related Sexual Risk Behaviors among Male-To-Female Transgender People in Nepal

Transgender women are a vulnerable and key risk group for HIV, and most research has shown an increased frequency of HIV infection among this minority population. This study examined the prevalence of HIV-related sexual risk behaviors and the socio-demographic correlates with HIV-related sexual risk behaviors among male-to-female (MtF) transgender persons.

Data were collected from a sample of 232 individuals through venue-based and snowball sampling and face-to-face interviews.

The HIV-related sexual risk behaviors among the MtF transgender persons were: sex without using a condom (48.3%), unprotected anal sex (68.1%), and unprotected sex with multiple partners (88.4%). Statistically significant differences were found for age, income, education, alcohol habit, and sex with more than two partners per day for these three different HIV-related sexual risk behaviors. MtF transgender persons with a secondary or higher level of education were three times (OR 2.93) more likely to have unprotected sex with multiple partners compared to those with a primary level or no education.

Age, education, income, frequency of daily sexual contact, and an alcohol habit remain significant with regard to HIV-related sexual risk behavior. There is an urgent need for programs and interventions to reduce risky sexual behaviors in this minority population.

Table 2Prevalence estimates for reported sexual risk behavior among transgender persons (n = 232)

Characteristics	Prevalence % (95% CI)
Alcohol in last 6 months	68.5 (62.6–74.4)
Smoking in last 6 months	58.2 (51.9–64.5)
Sex without using a condom in last 6 months	48.3 (41.8–54.8)
Unprotected sex with multiple partners in last 6 months	88.4 (84.3–92.5)
Unprotected anal sex in last 6 months	68.1 (62.0–74.2)
Unprotected oral sex in last 6 months	51.5 (45.0–58.0)
Other sex in last 6 months	6.1 (3.0–9.2)

...Unemployment and poverty were common among the transgender persons, as in other populations in Nepal. Nearly half of the respondents had no formal employment and a fourth of the participants indicated that they had a low income status, which is less than two dollars per day. The study also found that nearly a third of participants had sexual intercourse with more than one sex partner per day, which indicates a great risk for HIV and sexually transmitted diseases. A previous study has highlighted that the MtF population engages with a higher number of sexual associates.¹³

The findings regarding substance use suggest that alcohol consumption is widespread in the transgender population. This may be considered a serious public health problem, given that more than two-thirds of the participants had an alcohol drinking habit. Similarly, nearly three-fifths of the participants had a smoking habit. Unprotected sex with multiple partners was found to differ significantly by alcohol and smoking habits. Previous studies have found alcohol to be associated with HIV risk among sex workers and those having unprotected sexual intercourse.^{3, 27, 28, 29} However, there is no previous evidence for the association between HIV-related sexual risk behavior and smoking. Nearly half of the participants engaged in unsafe sex and did not use a condom with their sex partners. Previous studies have revealed irregular and low-level condom use among MtF populations.^{13, 18, 19, 20, 21} However, the great majority of the participants had multiple sex partners. Anal sex appears to be the most common sexual behavior among the MtF transgender persons.

The results showed no distinctive variations in HIV risk behavior among the age groups. Sex without using a condom and unprotected anal sex were found to differ significantly by age group. However, HIV risk behavior was found to be more common among the more educated participants. Educated respondents were three times more likely to have unprotected sex with multiple partners than the less educated and this was statistically significant. Previous studies have found the level of education to be positively correlated with unprotected sex.¹ Having very limited comparable data, the researcher proposes an explanation. Transgender persons with a higher education level may find it easier to build a network with varied sexual associates than less educated persons and may thus be further expected to engage in more unprotected sexual acts. They might be unaware that they are themselves at risk either because of the self-confidence that education may bring or because they are unaware or do not care to see their sexual partners as being at risk of HIV. Unprotected sex with multiple partners was found to be significantly associated with income. Risky sexual intercourse might be encouraged with the influence of money and somewhat higher in the highest income group than in the lowest income group.

Full article at: http://goo.gl/wgciqZ

By: Bhatta DN1.

• 1Department of Public Health, Pokhara University, Nobel College, Sinamangal, Kathmandu, Nepal. Electronic address: dnbhatta@yahoo.com.  

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