Learning from HIV to fight Covid-19 in Nepal

When Lalbahadur Shah of Birganj died last week, none of his relatives showed up for his funeral even though he tested negative for Covid-19. With no family, friends and neighbours attending, the Muslim community members took it upon themselves to perform his final rites as per the Hindu faith.

Shah had hypertension and diabetes, although he had tested positive for SARS-CoV-2, he had recovered from the infection. He succumbed to other health complications.

Across Nepal, people infected with the virus, even those who have recovered, have been shunned by neighbours and society. Migrant returnees and their families have been singled out and humiliated. Doctors and health workers have been harassed by landlords.

This is nothing new in Nepal. Tuberculosis and leprosy patients have been traditionally shunned. And the stigma associated with Covid-19 is very reminiscent of how people with HIV/AIDS used to be treated in Nepal in the past, and may have lessons for dealing with SARS-CoV-2, since the virus (like HIV) is here to stay.

“Physical distancing doesn’t mean discrimination and we should make people understand this,” says public health expert Aruna Uprety. “There is widespread panic about Covid-19 and this is turning people against those infected with it, exactly like it was with HIV/AIDS. This in turn is adding to the mental stress of the patients, undermining their recovery.”

Says Anjana Rajbhandary, a counsellor and columnist: "Social stigma is attached to lack of knowledge and when people know less, they feel the need to blame someone else because they are afraid of the unknown. Fear and anxiety about death and disease can lead to gossip, which results in stereotyping and discrimination."

Constant focus in the mass media on new infections and fatalities over those who have recovered has reinforced the misconception that Covid-19 is highly lethal, adding to the fear about it.

On Tuesday, Nepal reported a total of 1,016 new cases, its highest daily rise with 205 in Kathmandu Valley alone, forcing the local governments in Kathmandu, Lalitpur and Bhaktapur to reimpose lockdown for a week starting Wednesday midnight. So far, 17,580 people have recovered while 114 have passed away.

The number of new infections was down to 671 on Wednesday, 151 of them in Kathmandu Valley.

The similarities between HIV/AIDS and Covid-19 goes beyond stigma. Just like HIV/AIDS  spread like wildfire in western Nepal among families with husbands working in India, most of the Covid-19 cases were imported from India and spread among the poorest sections of Nepal’s most underserved region. And just like with HIV, Covid-19 is felling people with compromised immune systems.

Long-time HIV/AIDS activist Rajiv Kafle also sees parallels between the current Covid-19 crisis and the HIV epidemic of the 1990s in turning public awareness into behavioural change for prevention  Both diseases are caused by viral infections and attack the immune-compromised – only the method of transmission is different. While HIV is spread through unprotected sex, sharing needles or blood transfusions, SARS-CoV-2 spreads human-to-human through aerosol particles.

“As with HIV, I see a lot of denial about coronavirus. Back in the day, peer-pressure led people to partake in highly risky behaviour like sharing syringes. Peer-pressure today can be seen in the form of people pulling down their masks in presence of friends,” says Kafle.

Mass media was a crucial tool in the battle against HIV/AIDS in the days before social media. In particular, tv serials and docudramas featuring popular faces like comedian duo Madan Krishna Shrestha and Hari Bansa Acharya were highly effective in creating awareness about preventive measures such as safe sex and clean needles as well as in lessening the stigma for some 50,000 people living with HIV in Nepal.

Nearly 30 years later, Shrestha and Acharya are once more doing skits for public service announcements via social media and tv to spread awareness about Covid-19 preventive measures. The message is similar: while it was condoms and safe needles for HIV/AIDs, it is masks and distancing for Covid-19.

“If we were able to change peoples’ behaviour in something as sensitive as sex, then we should be able to do it much more effectively for Covid-19,” says Rita Thapa of Nepal Public Health Foundation, who was formerly with the WHO. “We still have time to work together with local authorities, civil society and the government to run mass awareness campaign that reaches down to the grassroots.”

Since this August, the government has started providing free TLD (once-a-day generic fixed-dose combination of tenofovir disoproxil fumarate, lamivudine, and dolutegravir), new antiretroviral drug considered the best regimen in the world for 17,000 people living with HIV in Nepal. Activists like Kafle credit this milestone to treatment literacy, community mobilisation and continued activism.

“Only a similar kind of dedication will guarantee accountability and transparency in terms of testing and treating coronavirus in Nepal when the vaccine and therapies aren’t available,” he adds.

Aruna Uprety recalls a recent field visit to Makwanpur district where she found Chepang nomads living without toilets or clean drinking water, who were not wearing masks and maintaining distance.

“It is now pretty clear we will have to learn to live with Covid-19 just as we did with HIV. What would help is strengthening our immune system to fight against the infection, be it by applying traditional medicinal or by eating nutritious indigenous food,” says Uprety. “But to prevent infection for now our first line of defence are masks, distancing and hand-washing.”