Print Version Bangladesh has a narrow window of opportunity to act decisively to prevent the spread of HIV/AIDS among vulnerable groups. HIV/AIDS prevalence and the number of AIDS cases remain low in Bangladesh, but they are on the increase in some risk groups. There have been little change in high-risk behaviors and vigorous and prompt action is needed now to prevent the virus from taking hold.  STATE OF THE EPIDEMIC Bangladesh, with a population of 136 million, had about 13,000 adults and children living with HIV at the end of 2002, according to UNAIDS estimates. However, since the first case was detected in 1989, till December 2004, only 465 cases were officially reported. Of these, 87 have developed AIDS, and 44 have died. Significant underreporting of cases occurs because of the country's limited voluntary testing and counseling capacity. The social stigma attached to the disease is a further impediment.     The HIV epidemic in Bangladesh is evolving rapidly. While overall prevalence rates are still low, high risk groups -- sex workers, injecting drug users and men having sex with men -- record much higher rates. In a pocket of injecting drug users in one area in Central Bangladesh, HIV prevalence rates jumped from 1.4 percent to 4 percent to 8.9 percent over a period of three years. This level of infection among IDUs poses a significant risk as the infection can spread rapidly within the group, then through their sexual partners and their clients into the general population. Another concern is the significant number of IDUs in the country who sell their blood professionally. Bangladesh relies on professional blood-sellers to meet most of the transfusion needs of its people.  RISK FACTORS Although overall HIV infection rates are low, Bangladesh is highly vulnerable to an HIV/AIDS epidemic due to the prevalence of behavior patterns and risk factors that facilitate the rapid spread of the virus. Risk factors include:  ·    Large Commercial Sex Industry: There are over 105,000 sex workers, both female and male, in the country. Brothel-based female sex workers reportedly see around 18 clients per week, while street-based and hotel-based workers see an average of 17 and 44 clients per week respectively.  ·  Low Levels of Consistent Condom Use: The majority of brothel-based sex workers report some sex without condoms with their clients. Country-wide, brothel-based sex workers report consistent condom use with 2.8 percent of their regular clients, and 5.2 percent with new clients. Among the clients, who include rickshaw pullers and truckers, only 1.5 to 4.6 percent report having consistently used condoms when buying sex from female sex workers.  ·  High Rates of Active Syphilis: Syphilis has been observed in 9.7 percent and 12 percent of female sex workers in central and south-eastern Bangladesh respectively. The high rates of syphilis and other STDs confirm the low level of condom use and the presence of other risky sexual behaviors that facilitate the spread of the HIV infection.  Needle-sharing among Injecting Drug Users (IDUs): More than 70 percent of injecting drug users in central Bangladesh routinely share needles. Hepatitis C prevalence rates of 83 percent have been found among IDUs. This is comparable to levels in countries that are experiencing a concentrated and growing HIV epidemic.  Lack of Knowledge among General Population: While knowledge of HIV is nearly universal among sex workers and their clients, it is inadequate among the general population. There has been some improvement in recent years, however. In 1996-97, only 1 out of 5 of married women and 3 out of 10 married men had heard of AIDS. By 2004, the numbers had risen and 3 out of 5 married women and 8 out of 10 married men were aware of the disease.  NATIONAL RESPONSE TO HIV/AIDS Government. In late 1996, the Directorate of Health Services in the Ministry of Health and Family Welfare outlined a National Policy on HIV/AIDS. A high-level National AIDS Committee (NAC) was formed, with a Technical Advisory Committee, and a National AIDS/STD Program (NASP) unit in the ministry. The NAC includes representatives from key ministries and NGOs and a few parliamentarians. Action has been taken to develop a multi-sector response to HIV/AIDS. Strategic action plans for the National AIDS/STD Program set forth fundamental principles, with specific guidelines on a range of HIV/AIDS issues including testing, care, blood safety, prevention among youth, women, migrant workers, commercial sex workers, and STDs.While earlier commitment was limited and implementation of HIV/AIDS control activities was very slow, Bangladesh has recently strengthened its programs to improve its response. The Government of Bangladesh has prepared the National Strategic Plan for HIV/AIDS for the period 2004-2010 under the guidance of NAC and with the involvement of and support of different stakeholders.  Non-Governmental Organizations (NGOs). Around 300 NGOs working in the area of STD/AIDS have formed a network, and about 135 are actively engaged in HIV/AIDS-related activities in the country, particularly in working with marginalized and hard-to-reach groups. NGOs are often in a better position than the public sector to reach high-risk groups, such as commercial sex workers and their clients and injecting drug users. Building the capacity of NGOs, especially the small ones, and combining their reach with the resources and strategic programs of the government is an effective way to change behavior in high-risk groups and prevent the spread of the virus to the general public.  Donors. The British Department for International Development (DfID), USAID, and the International HIV/AIDS Alliance are financing a number of HIV/AIDS control activities in Bangladesh. These include a social marketing program; peer education and condom promotion activities; information, education, and communication efforts; STD treatment; surveillance and operational research; and capacity building for NGOs.  ISSUES AND CHALLENGES: PRIORITY AREAS Vigorous action is required to prevent a widespread epidemic in Bangladesh. Key tasks ahead are as follows:  ·        Scale up behavioral change activities and health promotion interventions for high-risk behaviors and vulnerable groups. ·        Expand advocacy and awareness among the population at large through multi-sectoral agencies. ·        Promote the social acceptability of condom use and ensure adequate supply and access. ·        Reduce discrimination against those infected with HIV, or groups engaging in high-risk behaviors, through appropriate advocacy, policies, and related measures. ·        Strengthen the Government’s capacity for program implementation, monitoring, and evaluation. ·         Promote NGO capacity for program planning, implementation, monitoring, and evaluation. ·       Strengthen mechanisms for collaboration and coordination within and between government, the non-governmental sector, development partners, and other stakeholders.  WORLD BANK RESPONSE The World Bank supports the Government's two-pronged strategy: First, increasing HIV/AIDS advocacy, prevention, and treatment within the Government's existing health programs, and second, scaling up interventions among high risk groups.  The Bank has committed $20 million for an HIV/AIDS Prevention Project (HAPP), which became effective in February 2001. The project is scaling up interventions among groups at high risk in a rapid and focused manner, while strengthening overall program management. The World Bank and other donor agencies have supported advocacy and policy dialogue regarding the control of HIV/AIDS. This component has been included under the next sector program of the World Bank-sponsored Health, Nutrition and Population Sector Program (HNPSP, 2005- 2010).  The aim is to increase the availability and utilization of user-centered, effective, efficient, equitable, affordable and accessible quality services, be it the essential services package, improved hospital services, nutritional services or other selected services. June 2005 |
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