Kathmandu-based female sex workers who inject drugs now have access to a new drop-in space and access to a peer-staffed harm reduction project. Saarathi Nepal, an NGO which provides access to Opioid Substitution Therapy (OST) and promotes harm reduction through peer-managed projects has opened a drop-in centre for female injecting drug users in the Basantapur district of central Kathmandu.
The drop-in centre, which is home to the recently launched Saarathi Women’s Project is staffed exclusively by female drug users and aims to create a safe space in which women who use illicit drugs can organically create a strong social support network through engaging in community building initiatives and the exchange of peer-to-peer information, education and experience. Additionally, the space will also provide access to needles and syringes, safer sex prophylactics, Information, Education and Counselling (IEC) materials, and referral information. A new methadone dosing point is also due to begin operation within the same space in mid-February, 2015.
According to Surada Phuyal, a female peer outreach worker employed within Saarathi Nepal’s Women’s Project, a large percentage of Kathmandu-based female drug users engage in sex work to fund their drug use. Bijaya Dhakal, the current President and Project Director of Jagriti Mahila Maha Sangh (JMMS, the Federation of Female Sex Workers in Nepal) conceded, commenting that “Many female sex workers who use drugs move from smoking drugs to injecting drugs due the prohibitive price of illicit substances”. Ms Phuyal also stated that prior to the instigation of the Saarathi Women’s Project, Kathmandu-based female sex workers who inject drugs did not have access to a peer-staffed harm reduction project, nor had access to a peer outreach program.
Unlike other South Asian countries in which opioids such as heroin, opium and codeine are easily accessible and relatively low priced, opioids in Nepal are extremely expensive and difficult to obtain. Subsequently, many injecting drug users opt to use a combination of pharmaceutical drugs, commonly including buprenorphine, diazepam and/ or pheneramine/ phenergan. The liquid forms of these 3 substances are sold in 2mL vials and are substantially less expensive than traditional opioids. Due to strict national policies regulating the provision of pharmaceutical substances, these drugs are procured from pharmacies situated within Indian border towns and smuggled into Nepal for re-sale on the black market.
Harm reduction programs for sex workers and injecting drug users were only introduced to Nepal in the 1990s, and by 2002, approximately 68 % of Nepal’s injecting drug user population were HIV positive. However, due to harm reduction initiatives, supported by both NGOs, INGOs and the national government, estimates of HIV prevalence in 2014 identified that only 3% of injecting drug users were HIV positive. As of 2014, the HIV rate amongst female sex workers was estimated at 1.5 percent and 7.2 percent amongst male sex workers. HIV prevalence amongst the clients of sex workers is currently estimated at 4.4 percent.
Sex work is criminalised in Nepal and many illicit drug users face lengthy prison sentences if convicted of drug possession. Subsequently, women who engage in both sex work and illicit drug use face high levels of stigma from broader Nepali society, regular abuse and exploitation from police and judgemental attitudes from non-peer service providers. Resultantly, according to Ms. Phuyal, the susceptibility of injecting women sex workers to HIV is compounded by the criminalisation of sex work and illicit drug use, social marginalisation and ostracism, and gender inequality inherent in Nepali culture’s attitude toward women who challenge traditional gender roles.
Despite Nepal’s national policy of providing free Anti Retroviral Therapy (ART)/ Anti -RetroViral (ARV) medication to HIV positive people, many injecting sex workers who live in non-metropolitan areas face difficulty in accessing HIV treatment options. The issues faced by rural HIV positive sex workers who inject drugs primarily include economic deprivation, resulting in extreme difficulty in accessing long-distance transportation to hospitals specialising in HIV issues and treatment; a maximum prescription of 30 days of ARV/ART; the relative high cost of CD4, viral load and liver function testing (LFT); and a policy which requires people receiving ARV/ ART to undertake a mandatory CD4 count every 6 months in order to continue to receive free treatment. Further, many hospitals in rural areas lack adequate testing facilities and doctors with specialist knowledge of HIV issues. Subsequently, many non-metropolitan based HIV positive sex workers who inject drugs must self-fund monthly travel to Kathmandu for treatment.
Many HIV positive Nepali sex workers who inject drugs are highly susceptible to tuberculosis and many are also co-infected with Hepatitis C (HCV). Currently, access to Hepatitis C treatment in Nepal is prohibitively expensive and consequently many HIV positive Nepali women who use illicit drugs and engage in sex work are at increased risk of liver disease, liver failure and liver-related death. HIV/ HCV co-infection can also cause complications in the management of HIV, particularly in resource poor settings.
With the instigation of a new drop-in space for women who use drugs and engage in sex work, Saarathi Nepal ultimately aims to reduce the incidence of HIV, HCV and STIs amongst the injecting sex worker community, in addition to advocating for a wider range of peer-led harm reduction programs, and affordable access to HCV and HIV treatment options.