1. Why don’t Key Populations Access HIV
Testing and Counseling Center (HTC) in Nepal: Finding based on National
Surveillance Survey
Rachana Shrestha, Sairu Philip, Hemant Shewade, Keshab Deuba et al.
Public Health & Environment
Research
Centre, Nepal

2. Background Nepal Population: 29 Million- 2016
Economy: Low-income country
First HIV case detected & experiencing concentrated HIV
epidemic among key populations
HIV testing and counselling (voluntary) started
>170 HIV testing and counselling sites in the country
Men who have sex with Men and Transgender (MSM and TG), Female Sex worker(FSW)
Public Health & Environment
Research
Centre, Nepal

3. Objective
To assess the demographic, behavioural, psychosocial and structural factors associated with non-utilization of
HTC by female sex workers (FSW) and men who have
sex with men and transgender (MSM and TG) in Nepal
Public Health & Environment
Research
Centre, Nepal
Men who have sex with Men andTransgender (MSM and TG), Female Sex worker(FSW)

4. Definitions
Psychosocial Factors: Any exposure that may influence a physical health outcome or behaviors through a
psychological mechanism. [J Macleod, GD Smith JECH Volume 57, Issue 8]
Structural Factors: Barriers to or facilitators of an
individuals HIV prevention behavior. They may relate to
physical, economic, social, policy and other aspects of
the environment. [Sumartojo E, AIDS. 2000;14:S3-10]
Public Health & Environment
Research
Centre, Nepal

5. Study Population
MSM and TG: age16 years and above, self identified as either MSM or male to female TG and reported to have had sexual relations (anal sex) with another male or TG in the past year.
Female sex workers: women aged 16 years or above reporting to have been paid in cash or kind for sex with a male within the last 6 months
Public Health & Environment
Research
Centre, Nepal

6. Study Area
Public Health & Environment
Research
Centre, Nepal

7. Sample Size and Sampling Technique
MSM and TG
FSW
Sample Size
400
610
Sampling
Technique
Respondent driven
sampling
Two stage cluster
Public Health & Environment
Research
Centre, Nepal

8. Variables
Outcome variable: Have you visited (Yes vs. No) any HTC centers in the last 12 months?
(Reasons for visiting: pre-post HIV/AIDS test counselling,
information on HIV/AIDS window period, HIV/AIDS test result,
counselling on using condom correctly in each sexual intercourse,
etc).
Public Health & Environment
Research
Centre, Nepal
Documented differnet resoans for visitng hTC like counselling, testing

9. Independent variables
Socio-demographic : Age, Educational status, Marital status, Having dependent Behavioural : Condom use last sex, Ever inject drugs, Alcohol use Psychosocial : Depression, Suicidality, Social Support Questionnaire Score. Structural Factors: Housing Instability, Ever participated in HIV programs, Police detention in last 6 months, Experienced physical and sexual abuse last year. MSM and TG specific: Discrimination in Job and FSW specific: Client refusal to pay after having sex in last six months.
Public Health & Environment
Research
Centre, Nepal

10. Statistical Analysis
Mean and standard deviation (SD) values were computed for continuous
variables and frequencies for categorical variables.
RDS data: Based on the network characteristics of each participant, RDS-II
estimates were used for the calculation of probability weights and
RDS-adjusted prevalence.
Adjusted prevalence ratios (aPR) with 95% confidence intervals (CI) were
calculated by fitting a Poisson regression with robust variance estimates.
For RDS related data, we produced RDS adjucted prevalence based on the RDS II estimator
Public Health & Environment
Research
Centre, Nepal

11. Results Variables FSW N =610 % MSM and TG* N= 400
Non-utilization of HTC 55 69
Age (16-19 years) 17 18
No formal education 32 3
Condom use in last sex 75 76
Sexual abuse in last one year 20 6
Ever injected drugs 1
*RDS adjusted
Public Health &
Environment
Research
Centre, Nepal

12. Results Variables FSW N = 610 (%) MSM and TG* N= 400 (%)
Depression (CES-D)
Distressed / Depressed 44 33
Suicidality (ever)
Suicidal ideation 35 14
Suicide plan
34 (n=211)
42 (n=107)
Suicide attempt
28 (n=211)
35 (n= 107)
*RDS adjusted
Suicide plan was 34% FSW and , we asked about suicide plan and suicide attemplt only to those FSW and MSM who ever experienced suicidal ideation
Public Health &
Environment
Research
Centre, Nepal

13. Results: Factors Associated with Non-utilization of HTC among FSW
Variables
 Categorization
Adj PR
Ever inject drugs No
Ref.
Yes
1.4 ( )
Forced sex in last year
Ref
1.1 ( )
Psychosocial
Depression
Euthymic
Distressed
1.4 ( )
Depressed
1.4 ( )
Public Health &
Environment
Research
Centre, Nepal

14. Results: Factors Associated with Non-utilization of HTC among MSM and TG
Variables
 Categorization
Adj PR
Age in years
>25
Ref
16-19
1.4 ( )
Condom use at last anal sex
Yes
Ref. No
1.2 ( )
Physical assault in last year
1.8 ( )
Forced sex in last year
0.5 ( )
Public Health &
Environment
Research
Centre, Nepal

15. Conclusions
High prevalence of sexual abuse, depression and suicidality among FSW,MSM and TG in Nepal. Also negatively associated with non utilization of HTC.But no efforts
has been made to address burden of sexual abuse, depression and
suicidality among key populations in Nepal.
FSW, MSM and TG practicing high risk behavior (injecting drugs or non use of
condoms with client) were less likely to uptake HTC. Program should target
FSW, MSM and TG at increased risk of HIV to improve uptake of HTC.
Interventions should go beyond just distributing condoms, lubricants and
knowledge imparing activities. Address the burden of psychosocial and strcutural factors (depression, suicidality and sexual abuse) among key populations.
Public Health &
Environment
Research
Centre, Nepal

16. Acknowledgements Study participants NCASC The Union
Surveillance survey-related activities were funded by The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM)
Public Health &
Environment
Research
Centre, Nepal