1. HEALTH IS THE BEST WEALTH Experiences of women living with HIV in Nepal

2. 2 This is the story of community-based prevention of mother to child transmission (PMTCT) of HIV in Nepal. In Accham district, the mountainous terrain makes it difficult to access health facilities. By offering HIV testing as part of antenatal care at lower-level health posts, more women can access PMTCT services without traveling for hours or even days. With increased access to PMTCT, more children are born free of HIV. Through the support of female community health volunteers (FCHVs) and community home-based care (CHBC) teams, women living with HIV receive counseling, adherence support and commodities such as condoms, iron pills and tetanus vaccines. Since 2009, UNICEF Nepal and other partners have supported the Ministry of Health to provide and expand community-based PMTCT services in Accham district. As this story shows, decentralizing PMTCT services linked to community-based support is effective and even necessary in Nepal. All photographs ©UNICEF/Nepal/2014/Chandra Shekhar Karkai

3. MOTHERS CLIMBING MOUNTAINS What are called hills in Nepal are more like mountains. In Accham, one of the poorest and most remote districts in Nepal it can take hours and sometimes days of walking to reach a health facility.

4. BRIDGING COMMUNITIES AND HEALTH FACILITIES Since 1988, female community health volunteers have been providing counselling and health education in up to ten wards each. They encourage pregnant women to complete their four antenatal check-ups, take the necessary steps to have healthy babies.

5. DECENTRALIZATION OF HIV TESTING & COUNSELING Dammara Saud, above, is a female community health volunteer (FCHV). FCHVs refer pregnant women and families to the nearest birthing center or health post for antenatal care and to get tested for HIV. FCHVs also distribute condoms and provide counseling on family planning and safe sex.

6. PEER SUPPORT Community home-based care workers pick up where FCHVs leave off. CHBC teams visit people living with HIV in their homes to ensure they are taking their medications, attending consultations at the health facility and making referrals for social assistance, such as transport fees and food support.

7. HIV FREE TODAY I had two children after finding out that I am HIV positive. My daughter is three years old and my son is three months old. I followed the PMTCT programme with both of my children. My daughter received treatment and was tested at 18 months confirming that she is HIV free. I also gave her breast milk for 6 months like the nurses counselled me to do. I will do the same for my son. He was tested and so far the result is negative.

8. ANTENATAL CARE: THE DOORWAY TO PMTCT Indra, 25, is seven months into her third pregnancy and is living with HIV. She regularly visits Mangalsen district hospital for antenatal visits and prevention of mother to child transmission (PMTCT) services. She is a mother of two children: Vinita, 10 and Vipana, 8. Her husband, Jyagat, travels to India for seasonal work.

9. DIFFICULT NEWS Indra recalls learning that she was living with HIV two years ago, “I was so shocked that I neither spoke nor cried. I thought I would die soon.”

10. HOPING FOR AN HIV FREE BABY I’m 7 months pregnant, and because I lost one of my children soon after birth, I follow all of the nurse’s instructions. I am on antiretroviral treatment, taking one pill, once a day. My husband and I know we have to give the baby medicine and to test the baby after delivery. We are keeping all of our appointments and will follow the advice of the health workers. We know there is a chance our baby could be born positive, but we are hopeful that with PMTCT our child will be born free of HIV.

11. TREATMENT REALLY WORKS I regularly visit the hospital for follow up HIV treatment for myself along with my husband, because I know the treatment really works.

12. HEALTH IS THE BEST WEALTH The only dream that we have is that our children stay in school, so that their future is also brighter. I wish nothing more for them than that they stay as healthy as they are now. Health is the best wealth.

13. SUPPORT SYSTEMS I feel very positive and more hopeful than any other time because I have a lot of support from the nurses, community home-based care workers and my family. With all of the support, I am confident I can cope with this situation.

14. Zero cases of paediatric HIV Dr. Ram Bahadar Kessie, District Health Officer, Accham District We started community-based PMTCT here two years ago. This year we expanded HIV testing to 39 birthing centers, enabling us to reach rural areas. We plan to expand to all 75 villages in the district. We want to eliminate mother to child transmission of HIV in Accham district. We want to see zero cases of paediatric HIV, zero stigma and discrimination and to provide treatment for all community members who are HIV positive.