Vulnerability to HIV/STIs among Rural Women from Migrant Communities in Nepal: A Health and Human Rights Framework

Abstract

Human rights norms and standards can be applied to health issues as an analytical tool and as a framework to identify and shape interventions to reduce the impact of ill-health and improve the lives of individuals and populations. This article discusses how migration, health status, gender-based discrimination and access to education have an impact on HIV/STI vulnerability among rural women from migrant communities in Nepal. It is based on data from a clinic-based HIV/STI prevalence study with 900 women aged 15–49 from two rural communities in Kailali district, Western Nepal, and existing legal and policy data. Existing efforts to address HIV/STI vulnerability and risk in this population focus primarily on risk-taking behaviour and risk-generating situations, and largely fail to address contextual issues that create and facilitate risky behaviour and situations. Respecting, protecting and fulfilling the rights of individuals can reduce vulnerability to HIV/STI infection. Greater emphasis must be given to addressing the gender discrimination embedded in Nepalese culture, the acute lack of access to health care and education in rural areas, and the precarious economic, legal and social circumstances facing many migrants and their families.

Résumé

Les normes des droits de l'homme peuvent s'appliquer aux questions de santé comme outils analytiques et cadres pour identifier et concevoir les interventions qui réduiront l'impact de la morbidité et amélioreront la vie des individus et des populations. Cet article montre comment la migration, l'état de santé, la discrimination sexuelle et l'accès à l'éducation influencent la vulnérabilité aux IST et au VIH des femmes rurales de communautés migrantes au Népal. Il est fondé sur une étude menée en dispensaire sur la prévalence du VIH et des IST auprès de 900 femmes de 15 à 49 ans issues de deux communautés rurales de Kailali, au Népal occidental, et sur les données juridiques et politiques disponibles. Les mesures pour traiter la vulnérabilité et les risques de contracter le VIH ou des IST se centrent sur les comportements à risque et les situations créant des risques, et n'abordent pas les problèmes contextuels qui créent et facilitent ces comportements et situations. On peut réduire la vulnérabilité au VIH et aux IST en respectant et protégeant les droits des individus. Il faut corriger les nombreuses formes de discrimination sexuelle ancrées dans la culture népalaise, élargir l'accès aux soins de santé et à l'éducation dans les zones rurales et améliorer les conditions économiques, juridiques et sociales précaires de nombreux migrants et de leurs familles

.

Resumen

Las normas y criterios de los derechos humanos pueden aplicarse a los temas de la salud como una herramienta analı́tica y como un marco conceptual que sirve para identificar y diseñar intervenciones dirigidas a reducir el impacto de la mala salud y mejorar las vidas de individuos y poblaciones. En este artı́culo se examina cómo la migración, el estado de salud, la discriminación de género y el acceso a la educación tienen un impacto sobre la vulnerabilidad con respecto al VIH/ITS de las mujeres rurales de comunidades de migrantes en Nepal. Está basado en de un estudio de prevalencia de VIH/ITS en 900 mujeres de 15 a 49 años de dos comunidades rurales en el distrito de Kailali, Nepal Occidente, y en datos legales y polı́ticos existentes. Los esfuerzos por abordar la vulnerabilidad y el riesgo de contraer el VIH/ITS en esta población están enfocados principalmente en el comportamiento y las situaciones de riesgo, sin abordar los asuntos contextuales que crean y facilitan dichos comportamientos y situaciones. Se puede reducir la vulnerabilidad ante el VIH/ITS, protegiendo y haciendo respetar los derechos de los individuos. Hay que poner mayor hincapié en la discriminación de género inherente en la cultural nepalı́, la falta crı́tica de acceso a los servicios de salud y educación en las áreas rurales, y las precarias circunstancias económicas, legales y sociales que enfrentan muchos migrantes y sus familias.

Keywords:

• human rights
• HIV/AIDS
• sexually transmitted infections
• migration
• gender–based discrimination, health policies and programmes
• education
• Nepal

Human rights norms and standards can be applied to health issues as an analytical tool and a framework to identify and shape interventions that can reduce the impact of ill health and improve the lives of individuals and populations. A health and human rights framework can be used to:

•	identify rights that are applicable to a specific situation based on international human rights norms and standards,
•	analyse the content of laws and policies within a country and their implementation, and
•	consider how and to what extent insufficient realisation of rights causes or exacerbates vulnerability to poor health outcomes and an individual's ability to obtain adequate care and support once ill.1

This article uses a health and human rights framework, grounded in concepts of vulnerability, to identify issues that affect vulnerability to HIV/STI infection among rural women from migrant communities in Nepal. It argues that respecting, protecting and fulfilling the rights of individuals can reduce vulnerability to HIV/STI infection. It aims to provide insights that will lead to a more comprehensive approach to addressing HIV/STI infection in this population and potentially in other populations of women from rural, migrant communities.

The need to consider larger contextual issues which affect a person's vulnerability to and risk of a specific health outcome has been recognised as relevant to health research, policy and programmes.²³⁴ Specifically in the context of the HIV/AIDS pandemic, “the societal context within which people are born, raised, initiated to sexuality and sexually active strongly influences the degree to which they are or will be likely to adopt or avoid risk-taking behaviours.”⁵

Figure 1

Figure 1 Modeling vulnerability⁵

illustrates the vulnerability model and highlights the interdependence between the concepts of risk and vulnerability. Three levels of vulnerability have been identified: ²

•	Individual vulnerability, which includes aspects of both physical and mental development, as well as behavioural characteristics. Examples of individual vulnerabilities relevant here include history of abuse, low educational attainment, limited awareness of health and sexuality issues, and lack of sexual negotiation skills.
•	Programme-related vulnerability focuses on how the existence, content and delivery of health and development programmes either reduce or increase individual vulnerability. With respect to HIV/STIs, relevant vulnerabilities include those focusing on information and education, and health and social services for STI/HIV prevention, treatment and care.
•	Societal vulnerability includes political and governmental, socio-cultural and economic factors. Factors relevant to HIV/STI vulnerability among rural women include government interference with the free flow of information, gender inequalities, religious beliefs that prevent individuals from practising safer sex and lack of economic opportunities.3

Data and participants

This analysis draws on original data generated by the Harvard School of Public Health and Save the Children/US (HSPH/SC) and from existing legal and policy data. Primary data were collected from May to October 2001 during a clinic-based HIV/STI prevalence study with 900 ever-married women, ages 15–49, from two rural communities from Kailali district in Western Nepal. The clinic and study objectives were advertised to all women in these two communities, and the first 20–25 women to arrive at the clinic each day were chosen for possible inclusion in the study. All women attending the clinic, whether included in the study or not, were provided with the same range of medical services. The study sample was purposive, with 70% of women reporting that their husbands had migrated to India or to urban areas within Nepal for work. In addition to collecting clinical data and testing for various STIs and HIV, we asked about women's perceptions of changes in their own health, workload and financial security during their husband's migration; knowledge and perceived risk of HIV and other STIs; sexual negotiation and decision-making skills; and access to health care and other social services. Other data sources included interviews with representatives of governmental and non-governmental organisations (NGOs) in Nepal; existing legal and policy information on the protection of migrants' rights; and information about national laws and policies related to human rights, migrants, women and HIV/STIs and their implementation.

Health and HIV/STIs in Nepal

Nepal, a country of approximately 23 million people, is landlocked and shares long borders with Tibet to the north and India to the south. It is one of the poorest countries in the world, with a low per capita GNP (estimated for 1999 at US$220),⁶ life expectancy of approximately 54 years, high infant and child mortality rates and some of the highest maternal mortality ratios in the world. The adult literacy rate for women is approximately 35%, and for men 70%.⁷ Access to health care, including HIV/STI services, is still very limited. Most districts lack HIV testing and counselling facilities and access to antiretroviral drugs is virtually nonexistent. Few STI clinics exist, and health care providers have little training and inadequate medical supplies to diagnose and treat STIs.⁸

Relatively little is known about HIV/STI infection rates in Nepal. As of 1999, official estimates of HIV rates in the general population were 0.2–0.6%,⁹ but faulty surveillance tools and poor data collection make these estimates uncertain.¹⁰ No official estimates of STI rates exist for the general population either. Two recent prevalence studies offer insight into the potential extent of the epidemic in certain rural areas. A 2001 study among 610 rural men in Western Nepal found that approximately 2.3% of men were HIV-infected, while 13% were diagnosed with at least one STI. When the HIV rate was disaggregated by migration status, 3.7% of migrants to other countries, 3% of internal migrants and 0.7% of non-migrants were HIV-infected.¹¹

Because of migrant men's self-reports of risky sexual behaviours (including unprotected sex with sex workers, their wives or other regular partners), low levels of awareness regarding HIV/STI transmission and prevention, and difficulties in accessing treatment for HIV and other STIs, both while away and at home, migrant men may be serving as a “bridge” for HIV/STI transmission into their communities.¹⁰¹²¹³ Data among rural women provide further evidence of this. Our 2001 study in Western Nepal found that 11% of women were diagnosed with one or more untreated STIs. While HIV rates were low (0.3%), 4.5% of women were diagnosed with syphilis, 5.8% with trichomoniasis and 1.6% with gonorrhoea and/or chlamydia. Factors that were significantly associated with a woman having at least one STI, including HIV, included being over the age of 39, being divorced, legally separated or widowed, having undergone sterilisation or having a sterilised husband, and having a husband who migrated to India or within Nepal for work.¹⁴ No differences were found in relation to caste or ethnic group.

Policies and programmes on HIV/AIDS and STIs in Nepal

The government of Nepal has begun to address HIV/STI vulnerability and risk, but for the most part, these efforts have remained largely at the level of policy statements. Review of the 1997–2001 Strategic Plan for HIV and AIDS, produced by the National Centre for AIDS and STD Control, highlights “systemic factors”, including social norms and values, the poor status of women and high rates of geographical mobility. The Plan also suggests redrawing “the focus of analysis away from individuals…to the circumstances that create the whole, including the values of the economic, educational, cultural, social, legal and political systems which structure the world within which HIV is transmitted, and within which the epidemic has its impact”.¹⁵ Included within this is a call to strengthen the ethical, legal and human rights environment around HIV/AIDS, in order to create an enabling environment. In addition, the government's five-year development plan for 1997–2002 acknowledges that public health institutions have not provided people with adequate services, and blames this on inconsistencies in policies, programmes and budgets, managerial problems and the lack of equipment and human resources at health facilities.¹⁶ To date, few activities to address these problems have been carried out.

At the level of HIV/STI programming, a recent UNDP study found that while some HIV testing facilities exist, they were unavailable in many districts; no government counselling facilities existed in districts visited by the study team.¹⁷ Further, the Ministry of Health's Second Long-Term Health Plan (1997–2017) lists only condom promotion and distribution as priorities and while these are important strategies, there was no evidence of increased condom use among women in our study¹⁴, nor does this represent a comprehensive approach to reducing women's risk and vulnerability.¹⁶ The listed targets and accomplishments for the Department of Health Services 2000 Annual Report include generating 50 TV/radio programmes and/or newspaper advertisements about HIV/STIs, and producing 100 flip charts on HIV/STI prevention. These activities highlight mainly individual risk reduction strategies rather than contextual issues, however. Further, they depend on audiences having access to TV or radio, or being able to read. In a country where only 37% of rural women have regular access to radio and only 35% are literate, these interventions are unavailable and inaccessible to most.⁷¹⁷¹⁸ Finally, Nepal's National Policy on HIV/AIDS mandates AIDS and STD education for students from lower secondary level six to grade nine (ages ∼12–16). While this is critically important, it ignores the informational needs of the many young people who never attain this level of education.

Some strong NGO programmes exist in Nepal. Save the Children/US, together with its local partners Women's Inspiration Community, Lifesaving and Lifegiving Society and the BP Memorial Health Foundation, have created training manuals for educators focusing on HIV/AIDS. These resources have context-specific references and suggestions for dialogue with different target groups, and explore issues such as stigma, discrimination, the right to privacy and communication about HIV/AIDS in the context of Hindu and Buddhist cultures. They also focus on migrants and their families as primary target groups for interventions, by setting up STI support services for migrants, including treatment, referral and education, and providing training to health care providers on the specific needs of migrant families.¹⁹ Training also exists for media professionals and NGOs to build capacity in the field of communications and media development, with the goal of having the local media design, write and produce programmes on HIV/AIDS that encourage social development and behavioural change,²⁰ thus helping to reduce vulnerability to infection.

Many international NGOs, especially those with substantial funding, continue to focus primarily on populations considered as high risk, especially sex workers and injecting drug users.²⁰²¹ A related trend appears to be a shift towards an exclusive focus on behaviour change interventions.¹⁰¹⁷ Although some programmes call themselves “rights-based”, their emphasis remains largely on targeting individuals and their risk behaviours through the social marketing of condoms and behaviour change communication interventions.²² While these are all important efforts, they in large part fail to address the fact that much of the Nepali population has still not even heard of HIV or STIs, nor knows how to protect against infection.⁷¹⁴ They also fail to address the vulnerabilities of many rural women, who lack the power within their own intimate relationships to purchase condoms or demand condom use, or successfully introduce sexual matters or “behaviour changes” with their partners.

We found that four critical issues have an impact on vulnerability to HIV/STI infection among rural women from migrant communities in Nepal: migration itself, health status, gender-based discrimination, and because of its potential for inducing long-term change, access to education, especially for girls.

Migration

It is estimated that as many as one million Nepalese currently migrate to India for employment, while the volume of internal migrants in Nepal is estimated at 1.2 million.¹⁰²³ Most migrants are men, and most migration is circular, i.e. men work away from home and family for periods of several months, returning briefly for major festivals or to harvest crops. Male out-migration from some rural districts currently reaches levels of up to 70%.²³

Neither Nepal nor India, the receiving country for approximately 90% of Nepal's migrants,¹⁰ has ratified the 1990 International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families, and therefore neither country has explicit obligations to migrants and their families as such. However, both governments have obligations in relation to non-discrimination and the provision of just and favourable work conditions stemming from other human rights documents they have ratified.²⁴

No domestic laws specifically addressing the rights of migrants and their families exist in Nepal. The government vowed to create policies to regulate international migration in a recent Five-Year Plan, and conducted a migration policy analysis in 2000,²⁵ but no policies have been developed and no recommendations from the analysis implemented. Nepal does, however, have a 1950 Treaty of Peace and Friendship with India that addresses migration:

“Each government undertakes, in token of the neighbourly friendship between India and Nepal, to give the nationals of the other, in its territory, national treatment with regard to participation in industrial and economic development of such territory and to grant the concession and contracts relating to such development.”²⁶

Poverty, a lack of employment opportunities and the search for a better livelihood are the principal reasons for the out-migration of Nepalese to India each year. The reality, however, is often not improved opportunities. Nepalese often only have access to work that Indians do not want to take, including heavy manual labour, factory work, housekeeping and services such as residential and business security guards, all of which pay poorly and provide little extra money for family members left behind in Nepal.²³

Among the 628 women in the study whose husbands were migrants, 48% reported that their husbands sent no money home during migration and another 22% reported receiving money only once a year. These figures are in line with a recent government study, which showed that 57% of migrants do not send any money home.²⁵ In terms of amounts sent home, 74% of the women reported receiving less than US$65 per year, a small sum even by Nepali standards. Compounding this is the fact that sending money home can be risky in itself. Because there is no formal banking system between Nepal and India, migrants must carry whatever they have made with them, or trust friends to carry it home on their behalf. Robberies in which migrant men lose all of their earnings are reported to be common.²³

Limited economic resources lead to additional vulnerabilities for women, including reduced food security and increased workload. Twenty-nine per cent of the women in the study reported having less food during their husband's migration than before or after the migration period, while only 3% said they had more food. Sixty-two percent reported that their workload increased during migration, while less than 1% reported that their workload decreased.

Migration separates families, and separation has been found to correlate with both high levels of extra-marital sexual relationships and HIV/STI infection rates in other parts of the world.²⁷ Migrants often have more limited access to health information, including about HIV/STI and sexuality in their own languages, difficulties finding, accessing or being able to afford health care, and are discouraged from using health facilities for fear of being fired or deported if their employers learn that they are ill.²⁸ Thus, in relation to STIs and HIV infection, men's opportunities to seek diagnosis and treatment before returning home are hindered, which also makes women vulnerable.

Many women with migrating husbands in the study reported negative impacts on their health status and health-seeking behaviour, as money was only sporadically available for these needs. Forty-three per cent of women reported a perceived worsening of their health since migration began; only one woman thought her health was better. Reasons most often cited included having less money to obtain health care, having less food or poorer nutrition, and a heavier workload.

Health status

Although the right to health is not directly named in the Nepal Constitution, the Constitution instructs the government to pursue policies to raise public living standards and promote education, health and development of disadvantaged communities though “the principles and policies stated in this Part shall not be enforceable in any court.”²⁹

Limited access to health care contributes to poor health outcomes. The 2001 Nepal Demographic and Health Survey estimated that 75% of the rural population had inadequate access to sanitation facilities and 25% lacked access to clean water sources, figures much higher than for urban dwellers.⁷ Infant and child mortality rates were high,³⁰ and disproportionately high in rural communities. Over half of all Nepalese women received no antenatal care, and fewer rural than urban women received medical services and care during their pregnancies. Rural women also suffered from higher rates of stillbirth and early neonatal death than urban women.⁷ Kailali District is particularly poor and lacking in health care, ranking below the country-wide average in terms of infant mortality and child immunisation rates, the proportion of births attended by trained personnel and the health worker-to-population ratio.⁸

Few women in the HSPH/SC study reported seeking medical help for symptoms consistent with HIV/STIs, due to distances to health facilities and other barriers they faced once in the health care system, including not speaking the language used by health care providers and feeling uncomfortable speaking to providers from higher caste group. Many of those who did seek services found medical staff without proper training to correctly diagnose their condition, or proper drugs to resolve the condition.¹⁴ Untreated STIs facilitate the transmission of HIV,³¹³² yet many sexually active rural women in this study were left vulnerable due to untreated STIs.

Men's use of alcohol also appeared to be an important indicator for women's vulnerability to STIs. Women in the study who reported that their husbands consumed alcohol every day or almost every day were at significantly higher risk of having an STI than women who reported that their husbands occasionally, rarely or never consumed alcohol (OR 2.68, 95% CI 1.63–4.41).¹⁴

Gender-based discrimination

In its response to Nepal's 1994 initial report on its compliance with the International Covenant on Civil and Political Rights, the United Nations Human Rights Committee expressed its concern “that the principle of non-discrimination and equality of rights suffers serious violations in practices”, and concern “over the situation of women, who, despite some advances, continue to be de jure and de facto the object of discrimination as regards marriage, inheritance, transmission of citizenship to children, divorce, education, protection against violence, criminal justice and wages”. The Committee went on to say that the Government of Nepal “has not taken sufficient action to reflect the provisions of the Convention in domestic laws or to amend prevailing discriminatory laws” and noted that there was little information on the situation of women in rural areas.³³

Child marriage, which is common in Nepal, has potential consequences for women's health. Until 2002, Nepal's Country (Civil) Code stated that legal age of marriage with parental consent was 16 for girls and 18 for boys.³⁴ A younger legal age of marriage for women helps ensure the cultural norm of marriage to older men and indeed, the average age of marriage for women is three years younger than that of men.⁷ According to Cook, “laws permitting younger age at marriage for girls than boys promote the stereotyping of women in childbearing and service roles, and exclude them from the education and training that boys receive to fulfill their masculine destiny as family and social leaders”.³⁵ The newly amended law makes the legal age of marriage equal for men and women–18 with parental consent and 20 without parental consent.³⁶ Among the 95% of women in the study who knew their age at marriage, 45% were married before the age of 16, and 15% before the age of 14, with the youngest married at age six.¹⁴ The adoption of this new law could signify positive change with eventual implications for reducing gender discrimination.

With respect to dowry payment, a tradition among Nepalese of Indo-Aryan origin, in which a woman's family pays a man's family to take over responsibility for a daughter's maintenance, Nepal's Country Code states that “Except in cases where payments have been made and accepted according to the traditional custom, no girl shall be given in marriage for monetary or other consideration from the bridegroom's side.”³⁷ (emphasis added) The Country Code also exacerbates unequal power dynamics within marriage:

“No male shall, except in the following circumstances, marry another female during the lifetime of his wife or where the conjugal relation with his first wife has not been dissolved:

	- if his wife has any contagious venereal disease and it has become incurable;
	- if his wife has become incurably insane;
	- if no child has been born or remained alive within ten years of the marriage;
	- if his wife has become lame and unable to walk;
	- if his wife has become blind in both eyes.”37

Until 2002, the Code was silent with respect to the circumstances in which a woman could remarry; it has now been amended to allow women to remarry in the case of a man's sexual relationship with a third party. Whether women are in a position to act on this right remains to be seen. No other rights regarding divorce and remarriage for women have as yet been articulated. Furthermore, marital rape is excluded from the legal definition of rape, and weak prosecution and punishment of rape and other violence mean married women remain vulnerable.³⁶³⁷

With respect to property rights, recent amendments to the Country Code also signal some positive change. While daughters were formerly denied property rights within their families unless they remained unmarried until the age of 35, amendments in 2002 acknowledge that daughters as well as sons are entitled to property rights by virtue of birth. A woman who chooses to marry, however, is forced to give up her family property rights, suggesting that further legal change is still necessary to ensure gender equality in this realm.¹⁷

Because of these restrictions, women may feel they are forced to choose between staying in a bad marriage or leaving the marriage and potentially losing access to their children, marital property and economic security. Thus, women may be forced to have unprotected sex, and not only when they are fulfilling the duty to produce children for the marriage. Our data suggest that this dynamic may be important for rural women. When women in the study who had ever used condoms for HIV/STI protection were asked if they wanted to use condoms for HIV/STI protection more often, 93% responded yes. When asked why, 55% responded that they were afraid of HIV/STI infection, while another 2% responded that their husband had an STI and they needed to protect themselves.¹⁴

Access to education

Domestic law in Nepal states that five years of primary education is compulsory for both boys and girls,³⁸ but only 62% of boys and 28% of girls aged 15–19 had completed primary school in 2001.⁷ In 1999, the UN Special Rapporteur for Education identified the following ways in which gender gaps are manifested:

•	differences in literacy rates, reflecting a history of unequal access to education,
•	differences in school enrollment, reflecting continuing unequal access to education,
•	differences in primary school completion, indicating that enrollment does not necessarily lead to completion, and
•	a lower percentage of women teachers, which may also affect girls' enrollment rates; in Nepal, fewer than 25% of schoolteachers are women.38

In the HSPH/SC study, 84% of women reported having no formal education and fewer than 12% reported having completed primary school. Important correlations between women's exposure to education (both formal and non-formal) and their knowledge of health issues were also found. In terms of knowledge of STIs, only 41% of women in the study had heard of STIs, and only 40% had heard of AIDS.¹⁴ When disaggregated by level of formal education, 75% of women with some formal education had heard of AIDS compared to 34% of those with no formal education. When disaggregated by non-formal education status (one group having participated in an HIV education intervention and two other groups not having participated in any intervention), 76% of the intervention group had heard of AIDS, while only 22% of the non-intervention groups had heard of AIDS. When asked if there is anything a person can do to avoid STI infection, 13% of women said no or that they did not know of any way. Once again, disaggregated data showed disparities in knowledge rates between those women with formal or non-formal education, and those with none (data not shown).¹⁴

Conclusion

Use of a health and human rights framework grounded in concepts of vulnerability, has highlighted many issues that affect vulnerability to HIV/STI infection among rural women in Nepal. The legal and policy environment is beginning to change in positive ways, but meaningful change for rural women will be slower to come. Existing efforts to address HIV/STI infection focus on risk-taking behaviour and risk-generating situations, but largely fail to address the context in which these occur. In order to address HIV/STI vulnerability and risk fully, greater emphasis must be given to the many forms of gender discrimination, the acute lack of access to health care and education for many living in rural areas and the precarious economic, legal and social circumstances facing many migrants and their families in rural Nepal.

Acknowledgements

This paper draws upon Allison Smith-Estelle's DSc dissertation from the Harvard School of Public Health. The authors wish to thank the staff of Save the Children/US in Nepal, the Nepal Red Cross Society, SACTS, and the Forum for Women, Law and Development, as well as Ganesh Gurung, Allan G Hill, Stephen Marks, Rebecca Cook, Luni Shakya and Juni Shakya. Our sincere gratitude goes to the women in Kailali district who participated in the study. This study was supported by Save the Children/US, the Harvard School of Public Health, Harvard University, the J William Fulbright Commission and the American Association of University Women Educational Foundation. The views expressed do not necessarily reflect those of the funding agencies.