Can acceptance dismantle stigma and reduce HIV rates in Nepal?
July/August 2024 | Volume 23 Number 4
U.S. Embassy, NepalAn attendee views photos at the Sweekar Photo Exhibit in Kathmandu, Nepal. The exhibit features snapshots taken by rural trans women from the Madhesh Province, reflecting their experiences in connection with their gender identities and in obtaining HIV care.
Three in 10 of the 11.3% of trans women in Nepal living with HIV do not seek care. This is often due to the stigma of being
Hijra, or “the third sex." The Fogarty-supported Sweekar program aims to increase both HIV testing and treatment adherence by examining and addressing stigma faced by trans women in Nepal.
In ancient Sanskrit texts,
Hijra are described as capable of bestowing both blessings and curses. “Every temple you go to you see trans people's images. They're seen as mystic and people treat them with both respect and fear," said Dr. Erin Wilson, senior research scientist, San Francisco Department of Public Health. In rural Nepal, however, most trans people experience exclusion from society and discrimination. For the Hijra, this means “they’re highly regarded in the moment in which they're giving a blessing, but, once that moment is over, they’re highly disregarded,” said Wilson.
Regrettably, such stigma can lead Hijra, who are part of the larger trans women population in Nepal, to not seek medical care. Wilson and her colleagues are working on a stigma reduction intervention for Nepal's trans women community to increase their health care uptake.
The project’s name is “sweekar,” which means “acceptance” in Nepali.
Methodology
Wilson believes PhotoVoice, a participatory research tool, can help change attitudes toward trans women at the individual, community, and society levels. Participants take and share pictures of the ways in which they’re not accepted in Nepali society. For example, one trans woman photographed a boy with a water jug and explained that she’d never been permitted to perform this traditional female role (of getting water)—yet this boy was allowed. Wilson said, “It begins with getting the trans women together to talk about their experiences, to share how stigma manifests in their lives and what impact it has, and to find support with one another."
In addition to building empowerment, these photos will be used to launch a social media campaign aimed at changing attitudes within the wider society. Wilson and her research partner in Nepal, the Blue Diamond Society, are working with the U.S. embassy to garner support from regional thought leaders as well. “Stigma research shows that when leaders have different values, people say, ‘Maybe I should think about that.’ It trickles down to society.” At the 25th International AIDS Conference in July 2024, Manisha Dhakal, founding member of the society and co-investigator on the Sweekar grant, was awarded the Elizabeth Taylor Human Rights Award. Since its start in 2001, Blue Diamond Society has widened its focus from advocating for LGBTQ+ rights to providing HIV services.
U.S. Embassy, Nepal
Chargé d'affaires Jason Meeks of U.S. Embassy, Nepal (left), opened the Sweekar Photo Exhibit at Siddhartha Art Gallery.
The Sweekar project also addresses HIV treatment and prevention. Many living with HIV in Nepal can only access a month's supply of medication at a time. Nepal is small [56,956 square miles, roughly the size of Michigan], but it is mountainous, so traveling is arduous and time-consuming, observed Wilson. “Every month, they have to travel for hours and then stand in a queue at a hospital and wait for their meds.” Wilson’s team is working with Nepal’s National Center for AIDS and STD Control to facilitate wider access to multi-month dispensation.
“On the prevention side, we're hoping to implement HIV self-testing so patients can track their (and their partners’) status,” she said. “PrEP is still early in scale-up in Nepal. We need to start with the building blocks of getting and holding onto medications and getting access to testing.”
Social change
Nepal passed a law in 2007 to recognize those who identify as third gender, yet it hasn’t stimulated much change in societal attitudes. Most Nepalese live in multigenerational households and “being excommunicated from the family is traumatic. It’s a collectivist society with no social safety net,” explained Wilson. In Madhesh Province where Wilson works, many trans women hide their identity to remain within their families; they present as men and have wives, and then travel to India and work as Hijra. “If they identify as third gender, they give up their rights to marriage, their rights to prior education, their rights to inheritance.” Meanwhile, people will not buy milk from a trans woman if she has HIV (or is assumed to have HIV) and they won’t use her rickshaw. Wilson said, “This Fogarty grant gives us the opportunity to understand the stigmatizing attitudes that the general population in Nepal have—can we measure and change those?”
More Information
Updated August 20, 2024
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