Migration , HIV and Technical Education in Nepal

HIV and AIDS are crucial issues throughout the world. The first case in Nepal was diagnosed in 1988. Due to poverty, most of the people from the rural region of Nepal i.e. from the mid and far western region migrate to the neighboring country India to find work. During their stay in India, due to unsafe sex these migrants get infected with HIV and AIDS. After returning home these migrants transmits the diseases to their spouses. The children born from infected parents also get infected as well. The lack of technical education and vocational training compel these people to migrate in India to search for job without having any basic skill. The lack of knowledge on sexually transmitted diseases also increases the probability of getting infected. Therefore, it is necessary to make the people from the rural parts of Nepal aware of the sexually transmitted diseases, its causes and precautions. In addition, providing technical education and vocational training to rural people will enable them to secure more reliable job both outside and within the country.

People move from one place to another in search for job or better opportunities to maintain their livelihood.There are mainly two factors i.e. pull factor and push factor, which makes people migrate to new destinations.Nepalese are influenced by both these factors mainly due to economic instability and also for better opportunities.As discussed about the factors of Migration, both voluntary and forced migration are increasing trend in the world today.As some countries are facing internal conflicts and political instability, the people from these countries are forced to migrate from their native destination.Also, due to lack of opportunities, poverty and hardship is compelling people to migrate.Both these situations holds true in case of Nepal.The insurgency, political instability, lack of proper job and other factors are forcing the people from the Nepal to migrate.
It is widely believed that alarming number of migrant workers from Nepal are unskilled (69.1 percent) while corresponding figures of semiskilled, skilled, and highly skilled are only 27.1%, 3.4% and 0.4% respectively (Gurung, 2007, as cited in Council for Technical Education and Vocational Training [CTEVT], 2014, p. 1).However, people do not have the skill to get the good job as well as earn more amount because people do not have the technical education and vocational training to upgrade their skills and knowledge therefore people are compel to work in low wages and also not get the reliable job due to less skilled.
Migration is happening at a time when many countries are ill-prepared to deal with the changing demography and when policies and attitudes towards population movement and immigration are hardening.The health implications caused due to migration are many, and, in some cases, illness and death rates associated are exacerbated.This is mainly due to lack of policies needed to make migration a healthy and socially productive process.From a public health point of view, this is having-and will continue to haveserious ramifications for the people that move, the family they leave behind, and the communities that host the newcomers (Carballo & Nerukar, 2001, p. 556).
Migration is not a new phenomenon because, if we see the history of human society evolution from primitive society to industrial society, it was constantly migrating the people from one place to another in search for food or better life option.The possibility of migration is depended on how people perceive the world and their lives.Poverty is the main reason for people to move in search for better opportunities.In addition, conflict situation in one's country is also another contributing factor for migration.However, there are also challenges on public health because they may not get proper balance diet or they may be involved in unsafe behaviors (Carballo & Nerukar, 2001).Migrants are mostly poor people moving from poor economic environments, they carry with them the health profiles that result from poverty.Their understanding of health comes from having to adapt to poor ecological conditions along with limited possibilities for change and control over their own life (Carballo & Nerukar, 2001, p. 55).
People's movement across the borders for employment is increasing.This has a direct impact on the national economy.The remittance sent by the migrants back home also contributes in their countries' gross domestic product.UNAIDS (2008) estimates approximately 86 million people are international labor migrants.Both origin and destination countries benefit from the migrants, as the origin countries get the remittances and the destination countries gets employees and workers at a lower cost.However, it is necessary to focus on the HIV related issues among migrants especially labor migrants who are from poor economic condition.It is these migrants who are in risk due to lack of information and education.This risk from HIV and need of awareness, which must be addressed in striving towards universal access to HIV prevention, treatment, care, and support services by 2010 (UNAIDS, 2008).This article mainly focuses on labor migrant to India and situation of HIV among the labor migrants and how technical education can help to sustain their livelihood.

Migration and HIV Risk
There is risk of HIV infection among labor migrants in origin and destination countries due to social and economic factors.When people are migrated from origin destination, they leave their family members and spouse, besides this, they may have addiction to alcohol or other drugs.Due to the changing social context, when they may face languages barriers, socio-cultural influences and change in living conditions.The feeling of loneliness, stress and isolation may lead the migrant workers to engage in behaviors such as excessive drinking, unsafe casual or commercial sex, which increases the risk of HIV.This risk is further made worse by inadequate access to HIV services as well as fear of being stigmatized for seeking HIV-related information or support (UNAIDS, 2008).
Labor Migration and People Living with HIV Migrant labor who acquire HIV in foreign countries, or who are already living with HIV, often do not have access to HIV services.This is mainly due to the community that does not accept the HIV infected people as other people and stigmatize them.For this reason, the HIV infected person does not want to disclose their status.This contributes to make poor health condition for HIV infected people (UNAIDS, 2008).
Nepal is one of the major sources for migrant laborers, helping to fulfill the demands of the rapidly industrializing countries in Asia and abroad.Foreign employment provides an alternative livelihood for many young Nepalese (CARAM Asia, 2007; Asian Development Bank [ADB], 2009).India is the main destination to get a job for livelihood but migrant populations have a greater risk for poor health in general and HIV infection in particular.This situation has arised due to the impact of socio-cultural patterns of the migrant's situation on health, their economic transitions, reduced availability and accessibility of health services (National Institute of Development

Studies [IIDS], 2006).
A large number of Male Labour Migrants (MLM) from Western, Mid and Far-Western regions migrates to HIV burden areas of India.Due to their mobility and frequent return back home to their families, spouses are also at a higher risk of HIV transmission.The size of these returnee male labour migrants were estimated to be around 505,728 in 2011 (CBS, 2011 and NDHS, 2011 as cited in National Centre for AIDS and STD Control [NCASC], 2015b).According to department of foreign employment (2014), the data shows the trend of migration (both male and female) abroad which is mentioned in figure 1.The figure 1 shows that there is increasing trend in migration for both male and female.But, mostly people do not train on specialized course because the technical education and vocational (TEVT) program is available in certain geographical region in Nepal which cannot afford by all people who are migrated.Due to unskilled, people compel to involve in low level works that unable to earn the amount as they needed and cannot fulfill their basic needs.

Cross Border Migration & Risk of HIV
Nepal shares an open border with India.This means that there is no need for visa and other official documents to cross over and thus there are no exact records of migration flows to India.The estimated number of population that migrated to India is 722,255 (MoFE, 2014).According to IBBS 2015, a large proportion of the respondents (47.4%) has stayed in India for more than 36 months (NCASC, 2015b).If we analyze them from TEVT, they did not receive the any skillful training and education because mostly people are migrated in adolescent age as well as there do not have access on TEVT due to geographical regions as well as their economic condition.
More than 11 percent of the respondents confessed having sex with FSWs in India.UNAIDS study in 2014 found that only 10% of Nepalese migrants in India were aware of the availability of treatment for HIV.These low rates of antiretroviral therapy knowledge were found across the region NCASC, 2015b; UNAIDS, 2008) Nepal is categorized as a country facing concentrated HIV epidemic (NCASC, 2014).Government of Nepal shows that the estimated number of people living with HIV (PLHIV) is 39,249.Out of the total PLHIV, children (0-14 years) are 1,968, adults (15-49 years) are 28,869, and adults (50+ years) are 8,412.The adult HIV prevalence (15-49 years): 0.2%.The figure 2 shows the HIV prevalence among the targeted population and the figure 1 shows the male including male labor migrants have high prevalence of HIV which consists 40% and the spouse of migrants and low risk female found second highest HIV prevalence group which consist 34% (NCASC, 2014).

Figure 2. HIV Prevalence among Adults
The behavioral surveillance survey was conducted in every two years.In 2015, the surveillance survey was conducted among 720 respondents from western, mid-western and far western districts of Nepal.The HIV prevalence among male labor migrants in the mid and Far-West regions varies over time, being 1.4% in 2012, 0.8% in 2010, 1.8% in 2008, and 2.8% in 2006.In contrast, HIV prevalence among male labor migrants in Western Hilly has remained within 1.5% since 2006 to 2012 (IBBS 2012(IBBS , 2010(IBBS , 2008 &2006) &2006).HIV prevalence among male labor migrants in both regions is within 2% though is factually correct.But at the same time it may not be telling enough to convey an important message that even a small prevalence of HIV in the large population of male labor migrants ( of 505,728) obviously translate into a large number of people living with HIV (NCASC, 2015a).
Regarding the duration of stay in India, A large proportion of the respondents (47.4%) stayed in India for more than 36 months.Slightly higher percentage of the respondents who belonged to the Mid to Far Western Region ( i.e. 49.4% of the migrants)had 37 and more months stay in India, which when compared with the respondents of Western Region (45.3%) (NCASC, 2015b).

Sexual Behavior of Male Labor Migrants
More than nine out of every ten male labor migrants (91.1%) had ever had sex with female.The respondents of Mid to Far Western Region was higher (93.9%) than Western Region (88.3%).More than half (54.3%) of the respondents had first had sexual contact before the age of 20 years, whereas 3.4 percent of the respondents were less than 15 years old when they first had sex..More than one-third of the respondents (34%) had the first sexual contact between the age of 20-24 years and another 10.8 percent had experience of first sexual contact at the age of 25-29 years.A total of 17.5 percent of the respondents had ever had sex with female sex workers and this proportion was found slightly more among the respondents of Mid to Far Western Region (19.5%) than those respondents of the Western Region (15.4%) (NCASC, 2015b).Sexual Practice of Male Labor Migrants in Nepal Almost 8 percent of the respondents had ever had sex with Female Sex Workers (FSWs) in Nepal and this proportion was found slightly more among the respondents of Mid to Far Western Region (8.6%) as against the6.9percent of the respondents of the Western Region.Almost 36 percent of the respondents who had ever had sexual contact with FSWs in Nepal had this relationship with more than five FSWs.More than one-third (33.9%) of the respondents had sexual relation with 2-3 FSWs and almost one -fifth (19.6%) of them had sex with one FSW (NCASC, 2015b).

Sexual Contact with FSWs and Condom Use in India
The research shows that 5.8 percent of the respondents had sex with FSWs in the past one year and this involvement was almost similar among the respondents of Western Region (6.1%)and Mid to Far Western Region (5.6%).It is also shown that 45.2% of the male labor migrants had used condom during sex with FSWs in India, while 75.1 percent of the respondents had never had sex with FSWs in India.These behaviors also put them in high risk of HIV transmission because the main mode of HIV transmission is unsafe sex therefore mostly the male labor migrants who return from India have HIV infection (NCASC, 2015b) Prevalence of HIV among Male Labor Migrants Due to the unsafe behavior of migrants, the trends are increasing in the prevalence of HIV infection among male labor migrants.There was increase in the prevalence of HIV among MLMs from 1.1 percent in 2006 to the 1.4percent in 2008 in Western Region.Similarly, HIV prevalence among MLMs of the Mid to Far Western Region was 2.7 percent in 2006; which was reduced drastically to 0.8percent in 2008 but its prevalence increased to 1.5 percent in 2010.Out of 720 Male Labor Migrants (MLM) who participated in this survey, 3(0.4%) were identified as HIV positive (NCASC, 2015).Technical Education to Migrant Workers Rapid change can be observed in the skill composition of Nepalese migrant workers in recent years.The proportion of unskilled workers is decreased by 18 percentage point between 2004 to 2014, whereas corresponding figures of skilled and professional workers increased by 17 and 1 percentage point with in the same period of time.Nepalese foreign employment professionals have received increasing demand of skilled workers in recent years.This is also creating pressure to increase the supply of workers accordingly, however the capacity of training institutes in Nepal are not in the position to satisfy the received demand (CTEVT, 2014, p. 28).Currently, government has started to provide technical education and vocational training to migrant labor going abroad but this type of training and education are still lacking for those labor migrants who are currently working in India.If the labor migrants receive such technical education and vocational training, they will be able to sustain and maintain their livelihood without migrating to India.Even if they do migrate, they will get better opportunities and benefits due to the skill they possess.Being in a better position, migrants can be able to take their spouse along with them.This will certainly help reduce their sexual relation with FSW, which in turn will reduce the transmission of HIV.Proper orientation and education will help the migrants to take precaution and preventions from STD as well.Therefore, it is necessary to provide better orientations, skill related trainings, proper sex educations, knowledge on how to take precaution against STDs and other information to all labor migrants.The work standard, minimum wage, benefits, international labor norms, living conditions, and labor rights should be understood by all labor migrants as well.

Conclusion
Data shows that HIV prevalence is high among labor migrants.Also, the spouse of these migrants also suffers from the disease.Poverty along with HIV has made it hell for these migrants, who after being infected cannot continue to work.The cost for treatment is an additional burden to those already living poverty.Due to HIV infection among parent, children also contract HIV from birth, increasing the number of people living with HIV.The hope for these children is very little.Early death due to HIV has made many children orphan depriving them from the basic right to education and childhood.The technical and vocational training can play an important role to reduce such situations.By providing vocational education and technical training to the people in rural areas of Nepal, who are deprived from general education can help maintain their livelihood.Providing skill trainings and vocational education can help the people to open their own business and help them be self-employed within their country.Even if they do migrate to other countries, they can have better opportunities if they are equipped with certain skill.