Bajhang and Doti Districts are among the more remote districts of the Far Western Development Region (FWDR) of Nepal. These districts are characterized by a lack of NGOs, negligible infrastructure and insufficient reach of government programmes. Essential resources for local people's employment and livelihood are very much lacking and both districts do not produce enough food to feed their population. Also, there are high gender inequality and low literacy rates, especially among women (12%).

Given the problems described above, there is a high rate of migration, primarily among men (adolescents and adults), who leave their villages in search of jobs to support their families. A study conducted by CARE-Nepal revealed that 80-90% of households from the FWDR have at least one male migrating for work. Most of them are from low-caste strata. Anecdotal evidence suggests that a large concentration of Nepalese men from the western districts migrate to Indian cities such as Bangalore, Delhi and Mumbai.

Many migrant workers visit sex workers during their stay abroad. Having multiple sex partners and lack of condom use puts them at risk of HIV/STI transmission. Migrants are also vulnerable to infection due to their non-resident status in the host country, leading to inadequate access to awareness programmes, condom supplies and STI services. Therefore these men do not have preventive skills and knowledge to protect themselves against HIV/STIs. Similarly, the low social status of their female sexual partners, either their wives or sex workers, puts these women at risk of infection.

Hidden cases

The National Centre for AIDS and STI Control stated that 2800 cases of HIV were detected in Nepal by June 2003. Each month the average number of new cases is about 27. However, there are many more undetected cases; it has been suggested that the estimated number of people living with HIV/AIDS is almost 60,000 and the overall adult HIV prevalence rate 0.5%. A study on HIV/STI prevalence among selected villages in Doti District revealed that 10% of migrants were HIV-positive at random blood sampling. All of them had been to Mumbai for work. Among the tested men, 27-29% also suffered from some kind of STI.

A baseline study done by CARE-Nepal in 1999 demonstrated that most village men and women had insufficient knowledge on HIV/AIDS. Moreover, many health-care providers were also unaware of modes of transmission and prevention methods. There was a strong social stigma attached to HIV/AIDS among those who had heard about the disease, and no system in place to support HIV-infected people and their families.

Targeting men and their families

CARE-Nepal, in collaboration with Family Health International (FHI), started the migrant community programme in February 2002 to reduce HIV/STI-related risk behaviours among vulnerable population groups through community-based interventions. The programme is carried out in several communities in the Doti and Bajhang Districts. CARE-Nepal is implementing the programme with two local NGOs: the Nepal Red Cross Society and Samajik Bikash Samuha (Social Development Group). These NGOs increase their reach by mobilising community associations, such as youth groups and migrant wives groups, in the fight against AIDS. The main focus of the programme is on behaviour change through massive awareness creation and increasing the accessibility of condoms at the community level.

In order to sustain activities, emphasis has been given to building organizational capacity through CARE's technical assistance to local NGOs, district health offices and health posts in close coordination with district and village development committees (political bodies at the district and village levels).

"News from home"

The programme mainly targets migrant men and their wives. The migrant workers are given orientation on HIV/AIDS and STIs, which includes education on how to prevent infection. The men are approached on an individual and group basis by peer educators trained under the programme before leaving for work to India. Attempts are also made to follow up through education at their destination sites. A small cloth bag containing leaflets on HIV/STIs, along with personal messages from the organization and the migrants' wives, is sent by mail or given to other men going to the same place. The package, named Gaon ko Raiwar (News from Home), is meant to remind the men to take precautions while abroad. By June 2003, about 300 such packages had been sent to men at their work destinations. The response from quite a few migrants was quite encouraging. The men seemed to feel happy to receive letters and sexual health-related information.

A drop-in centre (DIC) at a bus stop entry point to one village in Doti District was established as a part of the programme activities. The DIC operator provides education, does condom promotion, and distributes IEC materials regularly. From the DIC, a counsellor catches up with migrant men emerging from the bus and before they proceed home. He talks to them about HIV/AIDS and STIs and hands over a small cloth bag named Sano Upahaar (A Small Gift) as a welcoming present. This bag contains a few condoms, leaflets on HIV/STIs, information on the places where condoms are available, etc.

Women

The migrants' wives have formed 146 groups who have been trained in both project districts. Every group has a peer educator group leader, who is approached regularly by the community facilitators of the partner organizations. They encourage and update the women with information on IEC tools and impart skills for sharing the information with their fellow group members. The group members are given a thorough orientation on HIV/AIDS and STIs, modes of transmission and ways to prevent diseases with the aim that they will educate more women in their villages. They are also expected to discuss and negotiate safer sex with their husbands when they return home.

Other activities of the community programme are:

• HIV/STI education for school teachers, female community health volunteers, school-going adolescents, participants of non-formal education groups, members of Youth Action Groups (YAG), key stakeholders and leaders in the community.
• Messages displayed in public places through wall paintings and billboards.
• Celebrations on HIV/AIDS Day and Condom Day (AIDS rallies).
• Community-based condom distribution centres (social marketing) in all project communities. These centres are functioning very well and there are clear indications that condom use is on the increase.
• Training of health-care providers (government health centres/local NGOs) on STIs and case management through the syndromic approach, and on HIV/AIDS.
• Training of traditional healers on referring patients to STI treatment facilities and other health services.

Lessons learned

One of the major lessons we have learned is that women play an important role in the dissemination of information to their fellow villagers and their husbands. These women have become more aware of the dangers of HIV/AIDS and are more conscious of the virus and its transmission.

We have also experienced the importance of social mobilization by reaching out to local community groups through our network of partner NGOs. The partner NGOs are more capable now of managing HIV/AIDS projects at the local level. Also, their staff are more motivated to carry out such projects, which leads to more interactions and acceptance at community levels. Due to this social mobilization many people seek HIV/AIDS-related information now and are willing to disseminate this information to others.

Another lesson is that men can be persuaded to change their behaviours and practice safer sex more effectively by involving fellow men from within their villages. Any programme should give special attention to men since it is difficult for women (wives) to initiate talk about STIs and HIV/AIDS and ask their husbands to use condoms when they come home during holidays.

Other lessons learned are that it is necessary to involve local government bodies, and that a drop-in centre can be very useful in terms of increasing accessibility to services and information to the targeted people. Finally, we have found that traditional healers are important in terms of referring people to health institutions for special care e.g., STI treatment. Therefore it is essential to include them in such programmes as key persons for service delivery.