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BACKGROUND: The transition to the "test-and-treat" policy in Nepal in 2017, coupled with the rapid initiation of antiretroviral therapy (ART) in 2020, necessitates an in-depth understanding of factors influencing ART initiation and retention. This study investigates these factors from the perspectives of healthcare providers, families/communities, and people living with HIV (PLHIV). METHODS: Employing a qualitative design, in-depth interviews were conducted with 24 ART clients and 26 healthcare providers across different provinces of Nepal. A comprehensive interview guide facilitated the exploration of experiences and perceptions. Interviews were transcribed verbatim, and thematic analysis was applied to distill key insights. Guided by a socio-ecological model, interviews were analyzed to identify the barriers and facilitators to ART initiation and continuation at the individual, family/community, and health system levels. RESULTS: Facilitators and barriers were identified at three levels. Individual-level facilitators included fear of death, perceived health benefits, knowledge about HIV/ART, confidentiality, and financial support. Barriers encompassed concerns about lifelong medication, side effects, denial of HIV status, fear of disclosure, and financial constraints. At the family/community level, support from family and community health workers facilitated ART adherence, while social stigma and discrimination posed barriers. The health system's role was dual; the provision of free treatment, a client tracking system and a robust drug supply chain were facilitators, whereas logistical challenges and service accessibility during the COVID-19 pandemic were notable barriers. CONCLUSIONS: This study highlights the various factors that influence ART initiation and retention in Nepal during the test-and-treat era. Tailored interventions should focus on increasing awareness about HIV and ART, strengthening healthcare systems, ensuring availability of medications, and providing accessible treatment during service disruptions. Furthermore, these interventions should encourage supportive environments at the individual, community, and healthcare system levels. Taking this holistic approach is essential for effectively implementing ART and achieving long-term health outcomes in light of changing public health policies.

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OBJECTIVES: This is the first nationally representative study to estimate the prevalence of viral load (VL) suppression and acquired HIV drug resistance (ADR) among people living with HIV (PLHIV) in Nepal. METHODS: A cross-sectional study recruited 1418 PLHIV from 20 ART centres in Nepal, using a two-stage cluster design. Participants were eligible if they were HIV-positive individuals on ART for 9-15 months or at least 48 months. Plasma specimens were collected and tested for the quantification of HIV-1 RNA. Specimens with a VL ≥1000 copies/mL were further processed for sequencing of PR and RT genes of HIV-1. The sequences were then analysed to detect mutations causing HIV drug resistance. RESULTS: The prevalence of ADR was 3.7% (95% confidence interval [CI]: 1.8-7.6) and 3.0% (95% CI: 1.8-5.2) among PLHIV who received ART for 9-15 months and 48 months or more, respectively. The prevalence of VL suppression was 95.3% (95% CI: 91.7-97.4) among those on ART for 9-15 months, and 96.5% (95% CI: 94.7-97.7) among those on ART for at least 48 months. The prevalence of any detectable acquired resistance to antiretroviral drugs was 80.7% (95% CI: 58.6-92.5) among those on ART for 9-15 months with VL ≥1000 copies/mL and 81.6% (95% CI: 55.4-94.0) among those on ART for at least 48 months with VL ≥1000 copies/mL. CONCLUSION: This study suggests that improved accessibility to VL monitoring and timely assessment of drug resistance in routine HIV programs are crucial in Nepal to ensure access to HIV treatment for all in need.

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BACKGROUND: In Nepal, personal drug use is criminalized and among people who inject drugs (PWID), the majority of whom are men, movement across the border with India for drug procurement and use is common. Using a risk environment approach, this study examined associations between border crossing and imprisonment with respect to HIV, HCV and injection risk behavior among men who inject drugs in Nepal. METHODS: This cross-sectional study analyzed data from 1345 participants from 14 districts across Nepal. Explanatory variables were prior imprisonment and past-month border crossing to procure or use drugs. We used multivariable logistic regression to evaluate associations between these variables and HIV, HCV, HIV/HCV co-infection and past-month injection risk behavior among PWID. RESULTS: Over half of participants reported prior imprisonment (34.6% prior to past year, 21.6% within past year) and Indo-Nepal border crossing in the past year to use or buy drugs (31.2% sometimes, 20.8% often); over one quarter of participants (29.6%) reported both. Imprisonment prior to the past year was associated with higher odds of all outcome variables: HIV (adjusted odds ratio (aOR) 2.44, 95% confidence interval (CI) 1.29-4.59), HCV (aOR 1.51, 95% CI 1.08-2.09), HIV/HCV co-infection (aOR 3.12, 95% CI 1.58-6.14) and injection risk behavior (aOR 1.64, 95% CI 1.20-2.25). Past-year border crossing to procure or use drugs was associated with HCV (aOR 2.06, 95% CI 1.42-2.98) and injection risk behavior (aOR 1.47, 95% CI 1.04-2.10), with larger effect sizes among PWID who reported both border crossing as well as history of imprisonment. CONCLUSION: Imprisonment and border crossing were associated with injection risk behavior and disease outcomes. These findings indicate a need to implement cross-border disease surveillance and harm reduction initiatives in the Indo-Nepal border region and in Nepali prisons.

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BACKGROUND: People who inject drugs (PWID) are at great risk of HIV and Hepatitis C Virus (HCV). In order to properly design interventions and develop programmes for women who inject drugs, this study assessed the prevalence of HIV, Hepatitis B, Hepatitis C, and syphilis and its risk behaviours among women who inject drugs in the Kathmandu Valley, Nepal. METHODS: Through modified network sampling in three districts in the Kathmandu Valley, Nepal, this cross-sectional study enrolled a total of 160 women who inject drugs. Participants' serum samples were tested for HIV, HCV, Hepatitis B virus (HBV) and syphilis and risk behaviours were assessed through a structured questionnaire. Primary outcome variables were HIV, HCV, HBV and syphilis prevalence, and secondary outcome variables were sharing needles in the past month and using condom in last sexual intercourse. Stepwise logistic regression was used to determine micro- and macroenvironmental factors associated with secondary outcomes. RESULTS: The prevalence of HIV, HCV, and HBV was 8.8%, 21.3%, and 1.9%, respectively. HIV-HCV co-infection rate was 5.6%. Fifteen percent of women who inject drugs reported transactional sex for drugs or money. One in four women who inject drugs (27.5%) reported that they were imprisoned or detained for drug related reasons. In multivariable analysis, women living with HIV who inject drugs were almost four times more likely to use a previously used needle/syringe than women who inject drugs who were HIV negative (aOR: 4.2 CI: 1.1-15.9, p = 0.03), but were almost four times more likely to use a condom during sexual intercourse (aOR: 3.5 CI: 1.1-28.9, p = 0.03). Enrolment in family planning was the main determinant for using condoms in last sexual intercourse (aOR 4.9 CI: 1.6-16.7, p = 0.006). Participants with access to HIV test and counselling (HTC) services were less likely to share needles (aOR: 0.3, 95% CI: 0.1-0.8, p = 0.01). CONCLUSION: Prevalence of HIV and HCV is high among women who inject drugs in Kathmandu valley of Nepal. Women who inject drugs enrolled in national programmes such as family planning and HTC were positively associated with condom use, and less likely to share needles.

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INTRODUCTION: The prevalence of depression and suicidality is high among men who have sex with men (MSM) and transgender women (TGW) worldwide. Stigma and discrimination are likely contributing factors. More research is needed in low-income, non-English speaking countries to assess the effects of social and structural factors on depression and suicidality among MSM and TGW. METHODS: Nepalese MSM and TGW (n = 340) were recruited using a respondent-driven sampling design and filled out a survey questionnaire. The outcomes were depression and suicidality. Data was analyzed using bivariate and multivariable logistic regression. RESULTS: More than half of the participants (59%) suffered from depression. Severe depression was more common among TGW compared to MSM (41 and 20%, respectively). When it comes to suicidality, TGW had higher lifetime prevalence of suicidal thoughts compared to MSM (32 and 5%, respectively). Depression was positively associated with sex work both for MSM (AOR: 7.9; 95% CI 3.4-18.2) and TGW (AOR: 6.5; 95% CI: 2.3-18.2). MSM who were evicted by family had high odds of suicidal thoughts (AOR: 6.2; 95% CI: 1.3-28.8). For TGW, suicidality was associated with being cheated and threatened (AOR: 3.9; 95% CI: 1.2-12.5) and having forced to marry a female (AOR: 2.2; 95% CI 1.1-5.1). CONCLUSIONS: Nepalese MSM and TGW suffer from a high degree of mental and psychosocial health issues. Future studies should focus on intervention research and on collecting data from a larger variety of gender and sexual minorities.

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