Nepal was the first South Asian country to report a case of coronavirus in January 2020, and been under a lockdown since March 24th which expected to extend until 14th June, after a second case was confirmed. Since then, coronavirus infections have been reported in 71 districts out of 77 in Nepal. As of 10th June 2020, Nepal recorded 4,364 confirmed cases and 15  reported deaths from COVID-19.

A landlocked country bordered by China’s Tibet Autonomous Region and five states of India (Uttarakhand, Uttar Pradesh, Bihar, Est Bengal, and Sikkim) with a population estimated of over 29 million and an economy that is still struggling to recover after the April 2015 earthquake with a magnitude of 7.8, Nepal has sought additional funding from international multilateral donors for the current and upcoming fiscal years to cover increased health care costs in the wake of the COVID-19 pandemic.

For Achut Sitaula, Executive Director of Trisuli Plus, an organisation led by People Living with HIV (PLHIV) and the Vice-Chair of the Country Coordinating Mechanism (CCM) Nepal, the unexpected COVID-19 pandemic brought about a whole new set of extraordinary challenges for the communities living with and affected by HIV, TB and malaria. According to UNAIDS data from 2018, Nepal’s population size estimate of people who inject drugs is 30,900 of which the HIV prevalence is estimated to be 8.8%, but the coverage of OST is at 2.8%, and it is estimated that 30,000 adults and children are living with HIV with an estimated 56% on treatment.

Therefore ensuring the provision of access to Opioid Substitution Therapy (OST) for people who use drugs was a key concern during the lockdown in Nepal as clients need to visit OST centres to personally collect their OST. Currently, the provision of OST to people who use or inject drugs in Nepal is supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria grant “To contribute towards the NHSP targets of 90-90-90 and equitable access to HIV services in Nepal. Disrupted access to these services meant complications in adhering to harm reduction treatment and may lead to increased vulnerability to HIV and STI infections.

Quickly responding to this threat, Achut worked closely with Recovering Nepal – the National Federation of People who Use Drugs and Drug Service Organisations in Nepal who played a vital role in successfully advocating to the Ministry of Home Affairs, National Centre for AIDS and STD Control (NCASC) Nepal to quickly organise its systems to ensure that OST services are delivered to those who enrolled for the service. During the lockdown in Nepal, this initiative delivered OST to more than 1,100 clients through outreach staff of Global Fund sub-recipient organisations.

The COVID-19 lockdown also created challenges in accessing quality treatment and prevention services which became extremely urgent as Nepal only had two months worth of Antiretroviral Therapy (ART) stocks available in the country due to delayed shipment of procured ART. Achut with the Nepal CCM immediately reacted with support from the Global Fund and PEPfAR to procure ARVs from India through Global Fund Pooled Procurement Mechanism and transport them to Nepal. After overcoming numerous obstacles including roadblocks, security checkpoints, and weeks of delays at the border crossing, Nepal now has adequate ARV stocks for and additional two months which is to be complemented with a year’s worth of ARVs with the expected arrival of ARVs procured by the Nepali Government.

“We must utilise our partnerships effectively in times of distress and rise up to and overcome the challenges. I cannot thank enough the tremendous support, time and commitment provided by Nicole Delany, Fund Portfolio Manager of the Global Fund, and Save the Children Nepal, Principle Recipient throughout this period,” Achut said passionately and added that, “The New Normal is to ensure that we work even more closely and collaboratively to meet the needs of our communities.”

In addition, the Nepal CCM worked to reprogram existing Global Fund grants to access flexibilities to continue delivering impact through existing grants to support the measures of the Government of Nepal in controlling and responding to the COVID-19 pandemic. US$1.37 million has been reprogrammed from Nepal’s Global Fund grants to improve health facilities, procure ventilators and personal protective equipment (PPEs), provide nutrition support to 1,300 children living with HIV, and purchase COVID-19 insurance plans for outreach staff of sub-recipient organisations. “It is paramount that we ensure the safety of our outreach workers who play a vital role in bringing essential  health services to our communities during these times,” Achut stressed.

As the CCM Vice-Chair, Achut also had to quickly respond and recalibrate plans with partners as the country prepares to submit its Funding Requests for HIV, TB and malaria components to the Global Fund 2020 – 2022 grant cycle by 31st of August 2020. The engagement of key and vulnerable communities through a transparent, comprehensive and meaningful process is vitally important to Achut as a community advocate and leader. Unable to organise in-person consultations with and for communities for the country dialogue process, Achut had to rely on virtual consultations conducted by networks of Key Populations in Nepal as the lockdown measures in Nepal initiated in March prohibited planned in-person consultations.

“The existing robust and widespread community networks provided a stronghold for us to conduct an extensive and meaningful community consultation process at the district and provincial levels,” recalled Achut who further emphasised the critical importance of community systems as a key element in supporting health systems, and the meaningful engagement of communities and civil society enabled designing sustainable and effective health interventions to key and vulnerable populations.

Over 68 consultations were conducted with the participation of over 1,500 key population participants for the HIV component funding request, over 25 consultations were conducted with affected TB communities with the participation of over 600 TB community participants for the TB funding request, and the Nepal CCM is currently conducting consultations with communities affected by malaria. However, Achut highlighted the need to develop similar networks to support prison and migrant communities in Nepal to ensure that these communities are also strengthened to meaningfully engage in community consultations to leave no one behind. 

Achut acknowledged the Global Fund CCM Evolution Initiative, of which Nepal CCM was a part of in 2019 during its first phase of implementation had contributed significantly to the successes the Nepal CCM had in responding to the COVID-19 pandemic, including the inclusive virtual country dialogue process. As part of the CCM Evolution Initiative, the Nepal CCM expanded its mandate beyond HIV, TB and malaria, and developed links with other stakeholders for a more resilient health response in the country. In addition, through the CCM Evolution Initiative, the Nepal CCM engaged more actively with the local and provincial governments of Nepal   which developed partnerships that enabled effective responses to HIV, TB and malaria community needs at all levels during this uncertain times. He also added that this would not have been possible without the technical support to support community and civil society engagement in CCM Nepal provided by APCASO – a regional civil society organisation with funding support from GIZ BACKUP Health (commissioned by the Government of the Federal Republic of Germany) to support civil society and key population networks to more effectively engage in CCMs

Despite the various accomplishments achieved together with partners and supporters, Achut pointed out that COVID-19 has brought to the forefront a much overlooked need of key and vulnerable populations – mental health.

As a former drug user who has experienced mental health conditions, Achut is sharply cognisant of the acute and  neglected need to address mental health conditions faced by key populations who are much more vulnerable to developing mental health conditions due to criminalisation, violence, abuse, stigma and discrimination, disownment by families, lack of employment, face laws that criminalise them, amongst other issues.

“I am also facing mental health conditions as a side effect of my ARVs, a reality that the majority of PLHIV on treatment face, but do not address,” revealed Achut.  He further elaborated that accessing mental health services is severely stigmatised, and there is a need to integrate mental health issues as an integral part of all interventions for HIV, TB and malaria holistically.

“Mental health is much discussed but less addressed for the three diseases, and COVID-19 presents an opportunity to ensure the inclusion of mental health interventions for HIV, TB and malaria,” concluded Achut.

Achut Sitaula

Achut Sitaula

Executive Director, Trisuli Plus

Achut has been living with HIV since 2002, and identifies as a former person who uses drugs. He is currently the Executive Director of Trisuli Plus, a community action group of PLHIV and people affected by TB. He was formerly the President of Trisuli Plus from 2007 to 2015, and was the President of the National Association of PLWHA (NAP+N) in Nepal from 2015 to 2019.

He is the Vice-Chair of the Country Coordinating Mechanism (CCM) in Nepal and a member of the Communities Living with HIV and affected by TB and Malaria Delegation to the Global Fund Board, and a  Member of the Union Community Advisory Panel (UCAP) of the International Union Against Tuberculosis and Lung Disease (The Union).

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