Published in Republica.
The freezing of US$10 million for HIV prevention aid money aimed to fund NGOs working with the most at-risk groups in the country – such as intravenous drug users (IDUs), prisoners, men who have sex with men (MSMs), and transgender (TG) populations – is having dire impact.
NGOs working with IDUs and MSM/TG populations have reported deaths linked to the funding gap.
IDU NGOs are hemorrhaging counseling staff, and don’t have medicine to help recovering drug users cope with pain and withdrawal. The country’s sole LGBTI (Lesbian, Gay, Bisexual, Transgender, and Intersex) NGO, Blue Diamond Society (BDS), has not been able to hand out condoms or lubricants for nearly three months.
At particularly high risk are the MSM/TG sex workers who depend on BDS services to perform their profession safely. “200 or 300 Rupees isn’t enough for the risks we have to take having sex without lube and with cheap condoms we get in stores,” explains Lucky*, a career transgender sex worker from Kathmandu.
The condom shortage crisis can be abated by purchasing them in local stores. However, for many sex workers, the cost of decent condoms is exorbitant, given their meager earnings, and the lack of lubricant makes sex for MSM/TG, even when using condoms, unsafe.
Personal lubricant is only available in a handful of stores in Kathmandu, and not at all outside of the city. At 600 Rupees for 50ml of lube, sex workers estimate it takes upwards of three sessions with clients to pay for one bottle. The amount of lube in a bottle lasts for just four or five sessions.
In addition to having no budget for condoms, lubricants, or STI testing services – three tenets of BDS’s successful HIV outreach work – the organization has been forced to slash salaries since July, leading a number of its employees to turn to sex work for survival.
Some of these employees, part-time peer educators tasked with teaching the marginalized LGBTI community in Nepal basic safe sex skills, have worked as sex workers throughout their tenure with BDS.
A part-time peer educator at BDS earns Rs 3,300 per month, which is often not enough to survive if one is expected to support a family.
“When the funding [for BDS] was good, I had condoms and lube and, with the salary, I felt safe because I could afford to reject clients who scared me,” explains Jewel, a transgender peer educator in Kathmandu who has been a sex worker while working for BDS for nearly ten years. “Now I don’t feel safe because I have to say yes to everyone – I need the money.”
“Sex workers, transgender populations, injection drug users, men who have sex with men, and other populations who may be subject to stigma are particularly vulnerable to violence, abuse, and exclusion from access to services,” explains Marianne Mollmann, senior policy advisor at Amnesty International.
So when a funding gap halts the services that keep these populations healthy, it exacerbates the marginalization of these communities, and increases the level of risks they experience in their daily lives.
Donors take note
The World Bank, which pools HIV donor funds for Nepal from a handful of governments, has approved the NGO applications for funding and transferred the money to the government for distribution.
That disbursement was scheduled for January 2011. Since then, however, the government simply hasn’t released those funds because of changes in personnel, complaints about the lack of transparency, and dismissive concerns that the money might be needed elsewhere.
On September 21, with the funding gap over two months old, the World Bank wrote to Health Secretary Dr Sudha Sharma highlighting the danger that the funding gap would cause for the lives of at-risk populations: “…we have now reached a point where … efforts are all but exhausted and service interruption is likely unless the contracts are signed immediately.”
In short, donor confidence in the Nepali government’s health system is eroding. Frustrated that their pleas to the government are being ignored, donor countries and agencies have even threatened to take their money back.
In the barren rooms of BDS drop-in centers across the country, the gap is already being felt. In the cruising sites where sex workers meet clients nightly, increased risks are encountered.
Affected organizations fighting back
Blue Diamond Society, with director Sunil Babu Pant, MP, at the helm, has refused to give up hope that the government will do the right thing. As a result of the disruption in services, BDS, getting increasing reports of desperation – and even deaths – from their constituents, brought the disruption back to the government.
Paying their own way with borrowed money or paltry savings, on Sunday, September 25, more than 300 BDS members from across Nepal – mostly MSM and TG – traveled to Kathmandu.
Many of them are peer educators, the vessels of HIV intervention work in communities across Nepal. None of them has been paid since July; some not for several months before that.
A meeting with the Director of the National Centre for AIDS and STD Control (NCASC) led the group of activists to Dr Sharma’s office at the Ministry of Health and Population (MoHP) where, they were told, the contracts sat waiting for her signature.
A regional coordinator from Itahari delivered the message to Secretary Sharma: “The government’s failure to deliver the needed funding is undercutting programs which are successful in reducing the transmission of HIV-AIDS.”
The numbers – and the measurable impact – are impressive. The officially accepted estimate of MSM/TG in Nepal is 128,000. At least 6,000 are living with HIV. In 2010 alone, BDS distributed over a quarter of a million lube packets, and nearly half a million condoms.
The organization’s 41 offices across the country registered over 11,000 new MSM/TG (including sex workers) and administered over 4,000 HIV tests.
Bishnu Pandey, the regional coordinator in Bhairahawa, beamed about the success BDS programs have had with the LGBTI community despite its extreme marginalization: “We use local networks. We teach sex workers about safe sex, empower them to teach others, and they come in for testing, for condoms and lubricant and counseling.”
Pant gestured around the room to his employees who had trekked into the city to demand the funds be released: “They have come to show you that it’s their lives being affected, their communities. These are essential, basic services for health and survival. This is real suffering.”
Secretary Sharma’s initial excuses for the delay matched World Bank’s documentation, which explained that delays “occurred due to a number of reasons such as turnover of government officials, a court case, and investigations of complaints.”
Her second explanation hinged on the Ministry’s indecision as to who should sign the contracts – the Director General, or the Secretary. BDS representatives again requested that she complete the contract process – for the sake of respect for the basic human rights of MSM/TG.
“This sort of thing is and isn’t a human rights issue,” she replied. She explained that she wanted to help and expedite the process now, but that it’s “important not to dramatize it by saying that all of these things are human rights violations.”
Bureaucratic ineptitude puts lives at risk
To observers familiar with Nepal’s bureaucracy, this current funding crisis is all too typical.
As early as February, the World Bank had warned that the Nepali government needed to be quick and efficient in administering the funds in order to avoid a gap. In a letter to MoHP, the Bank clearly explained that the bidding and contracting process would take at least some months.
In addition to the warning, the Bank suggested an easy way to safeguard against a gap: the NGOs currently providing the services to the most at-risk populations were, for the most part, the same ones applying for the new round of funding.
What is more, they had a well-documented track record of success. As such, the Bank recommended “that the Ministry contract NGOs that are currently providing these services for an additional 2-3 months.”
However the Ministry acted in direct opposition to this advice, rejecting the BDS application on a technicality: the Ministry claimed that Bank rules dictated a minimum of three bidders per at-risk group. BDS is the only NGO to ever apply for MSM/TG HIV funding; after a two month delay for all applicants, the same BDS application was accepted.
An HIV official who has worked in Nepal for 20 years and asked to have her name kept confidential explained cogently, “Even when funds stop for services, it doesn’t mean lives stop. People continue to behave like normal – have sex.”
If they do sex work, they continue. If their part-time salaries are cut, they increase their sex work to make up the difference. Sex work, that is, without the basic tools for protection that they have been trained to promote.
“I’m not ashamed of doing sex work,” says Lucky. “I’m good at my job. I’ve always been safe and professional, and I support my parents who are old, even though they don’t like my transgender identity.”
But the consequences of health funding gaps can have devastating impact on the lives of sex workers as well.
“I got HIV about six years ago,” explains Jewel. “It was during a lube shortage. The cheap condoms I was buying would break. I still do sex work when I need to, but I always use protection.”
As marginalized and at-risk communities wait for the government to sign papers nine months late, lives continue to be lived. If the eroding donor faith in Nepal can’t catalyze the bureaucracy, perhaps knowing that thousands of people are suffering needlessly will.
Mollmann of Amnesty International explains that when dealing with populations that may be subject to stigma in healthcare access, human rights standards “put an additional obligation on the Nepali government to ensure that no one is discriminated against in terms of accessing healthcare services and other human rights.”
As of today, however, the contracts remain unsigned, despite the MoPH continuing to promise to do so.
*All the names of the sex workers interviewed for this article have been changed to protect their privacy.