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HIV/AIDS: Bangladesh country situation

DR AZM ZAHIDUR RAHMAN
THOUGH at present Bangladesh is categorised as a low HIV prevalence country, from an epidemiological point of view the HIV epidemic in Bangladesh is evolving rapidly. Bangladesh has a relatively low prevalence of less thlan 1 percent among vulnerable groups except in Injecting Drug Users (IDUs) where HIV positivity has rapidly increased from 1.7 percent in 2000/2001 to 4.9 percent in 2004-05 in central Bangladesh. The most alarming news is that -- during 5th round of surveillance in 2003/2004 -- in one pocket of central Bangladesh HIV infection rate among IDUs has reached concentrated epidemic level of 8.9 percent. During the sixth round in Central-A1, out of 664 IDUs covered, 7.1 percent tested positive for HIV. On top of that for the first time HIV was detected in cities other than Central-A during the sixth round. These two new places are Southeast-D and Northeast-F1 with the HIV prevalence rate among IDUs at 0.6 percent and 2 percent respectively.
According to the National AIDS/STD Programme (NASP) the estimated number of people living with HIV (PLHIV) was around 7500 as of end of 2004. As of December 2004, a total cumulative of 465 cases of HIV/AIDS have been confirmed and reported by the Ministry of Health and Family Welfare (MOHFW) with 87 of these having developed AIDS, out of which 44 have already died. Significant underreporting of cases occurs because of the country's limited voluntary testing and counseling capacity and inadequate reporting system. The social stigma attached to the diseaseis a further impediment.
5th round HIV surveillance also
have sex with males (MSM) only two
revealed high Hepatitis C (HCV) prevalence in IDUs as 54.2 percent tested positive for HCV out of 1619 IDU sampled. During the Sixth round testing for HCV among IDUs done in eight sites, the HCV prevalence varied from as low as 2.5 percent in South east-D to as high as 57.5 percent in Northwest-D.
The present level of HIV infection among IDUs poses a significant risk as the infection can spread rapidly within the group. Moreover a large proportion of IDU had commercial and non-commercial female sex partners and condom use was infrequent. So, there is every possibility of spreading the infection through their sexual partners and their clients into the general population. Another concerns is the significant number of IDUs in the country who sell their blood professionally. According to the 5th round behavioural surveillance (2003-04), 4.36.7 percent IDU sold blood in the previous year. At the same time IDUs are highly mobile and travel to different places, where they inject drugs and share needles.
Among female sex workers HIV prevalence during the sixth round remained low as with the previous rounds. It was less than 1 percent among all groups of female sex workers except the casual female sex workers in one of the northwest border areas (Northwest-K1) of the country in a sample 120 sex workers, where the prevalence rate is 1.7 percent. Though declining, active syphilis rate among female sex workers is still high ranging from 1.6 percent to 10.7 percent in different locations of the country (sixth surveillance report). Moreover, female sex workers in the border areas are considerably mobile and sale across the border.
Out of 919 samples of males who
MSM tested positive in the sixth round. Active Syphilis ranges from 3.8 percent to 5.6 percent in three different sites among this group.
Among the bridge population groups 398 Truckers, 401 Rickshawpullers and 395 Dockworkers were tested during the sixth round of surveillance from three geographical locations of the country. None of them were HIV
positive.
Behavioural surveillance data of different rounds also shows that Bangladesh cannot have complacence at this moment, because risky behaviour is very common. Let us look into some of the findings of behavioural surveillance data of different rounds.
> More than 90 percent of the respondents among street based sex workers and rickshawpullers of south-eastern part of Bangladesh cannot even name two correct ways of contracting AIDS.
> Men have not reduced commercial sex: About three quarters of truck drivers and rickshawpullers, and 60 percent of male injection drug users reported sex with female commercial partners in the past year.
> Fourth round of national HIV and behavioural surveillance revealed that 33 percent of the surveyed college and university students reported to have sex with commercial sex workers last year.
> Higher level of commercial sex in Bangladesh than elsewhere in Asia: Sex workers in Bangladesh brothels report among the highest turnover of partners anywhere in Asia, at an average of 18.8 clients per week. Averaging 44 clients a week, hotel based sex workers are still higher. This high turnover is very important, because it means that once a woman does contract HIV from any of her clients, she can pass the infection on to a large number of people very quickly as the condom
use is still very low while someone buying sex in Bangladesh.
> Condom use during commercial sex is distressingly low: Two-thirds of rickshawpullers and nearly as many as truck drivers reported that they had never in their entire life used a condom.
> Condom use among female sex workers is the lowest in Asia.
> Needle sharing is routine among drug users here. In central
part of Bangladesh two out of three reported receptive needle sharing in the past week, while three out of four did the same in southeastern part.
There is a common notion -- as Bangladesh is a predominantly Muslim country and people follow the religious norms meticulously, HIV/AIDS would not be a problem for us. But the above information clearly tells about our real practices, which does not always fall within the boundary of our religious norms -so we also stand equally vulnerable as other people in the world. Considering the overall situation if we look at the vulnerability factors for Bangladesh, we would find a long list--
l Geographical location: Bangladesh is in close proximity to parts of India and Myanmar where HIV prevalence is considerably high at different locations, and Nepal that has a concentrated epidemic among IDUs. The porous borders with legitimate and informal both way traffic also fuel the situation.
l Overlap between more vulnerable and bridging populations: The 'so-called' high risk or more vulnerable people are having interaction with the general population
- IDUs are also sexually active with married partners and sex workers.
- A client of sex worker is also having sex with his wife.
- IDUs, male having sex with male (MSM), female sex workers, clients of sex workers all these subgroups have sexual interaction.
- 47 percent of MSM are married and having sex with their wives.
l Female sex workers in Bangladesh have the highest turnovers of clients in Asia.
l Extremely low levels of condom use in commercial sex.
l Low levels of HIV and AIDS awareness:
- Only 31 percent of ever-married women and 50 percent of currently married men had heard about AIDS
according to the report of the 19992000 Bangladesh Demographic and Health Survey (BDHS)
- While 66-87 percent of the IDUs knew that needle sharing spread HIV, 90 percent of IDUs were unaware of the risk from male-tomale sex or sex with hijras.
lPoverty linked vulnerabilities:
- The richest male population group was twice as better informed about HIV prevention than the poorest
- Gender bias in knowledge levels are also evident
- Bangladesh has a large number of overseas migrant workers
- Migration between rural and urban is also high
- Seasonal migration within the country
- Extensive trafficking in women and children
- Children in general are at risk of sexual harassment, exploitation, and abuse, specially the street children.
• Gender inequalities:
- Women and adolescent girls are more susceptible to STI/HIV infec-
tion than men due to biological and other factors.
- Women are often taught to leave the initiative and decisionmaking about sexual matter to men. The male need is expected to predominate in this society.
- Women lack the power to refuse sexual activities, which may infect them because they lack economic empowerment. They are unable to
demand that their husband or male partner use condom regularly as they cannot afford to jeopardise his support.
- An AIDS widow is deprived of the inheritance from in-law's family. l Gaps in healthcare delivery system
- Blood transfusion practice in Bangladesh is still complex and may be conducive to transmission of STI/HIV infections. Though legislation on safe blood transfusion approved by the government and blood is now screened at 98 hospitals across the country, but lot of private and public centers do not have the required facilities.
- Voluntary blood donation increased from 10 percent to 31 percent, and 20 percent to 25 percent relatives donate blood when needed, while professional blood donation has decreased from 70 percent in 1997 to 19 percent.
- Biomedical safety issues and universal precautions are not observed at all healthcare facilities.
- Healthcare personnel need appropriate training to handle the medical needs of people living with HIV/AIDS, especially the prenatal and post natal needs of HIV-positive women and infants.
- Healthcare system needs to have more capacity to deal with women.
- Private healthcare facilities and diagnostic laboratories need regular monitoring.
Needless to say that it is high time to consider seriously about all these
issues of vulnerability to HIV/AIDS. Though we are still a low prevalent country, but we have no time for complacency. Rather we should think ourselves fortunate that we have got some extra (!) time to combat the situation and we should not miss this golden opportunity. Bangladesh can still avert a potential HIV epidemic, if action could be taken at this very moment. It should be NOW; any delay would be fatal. Looking at our country situation we have to focus on our priority areas. Lot of action is required to prevent a widespread epidemic in Bangladesh. Some of the key task would be
--
l Scaling up behavioural change activities and health promotion interventions for high-risk behaviours and vulnerable groups.
l Expanding advocacy and awareness among the population at large through multi-sectoral agencies. Mainstreaming of HIV/AIDS activities.
l Promoting the social acceptability of condom use and ensure adequate supply and access.
l Focused programmes for women and adolescents and ensuring women and adolescent friendly services.
l Promoting legal and institutional support in favour of HIV/AIDS prevention activities by enacting necessary laws.
l Ensuring community-driven initiatives to motivate safer behaviour practices.
l Strengthening care and support programmes and voluntary counseling and testing facilities.
l Reducing discrimination against those infected with HIV, or groups engaging in high-risk behaviours, through appropriate advocacy, policies, and related measures.
l Strengthening the government's capacity for programme implementation, monitoring and evaluation.
l Promoting NGO capacity for programme planning, implementation, monitoring, and evaluation.
l Strengthening mechanisms for collaboration and coordination within and between government, non-governmental sector, development partners, and other stakeholders.
l Promoting greater involvement of the different vulnerable groups specially with people living with HIV/AIDS.
Genuine leadership and political
commitment is instrumental at this point. During United Nations General Assembly Special Session on HIV/AIDS (UNGASS) in June 2001 heads of state and representatives of government issued the 'Declaration of Commitment on HIV/AIDS' -which is a powerful tool to guide and secure action, commitment, support and resources for all those fighting the epidemic, both within and outside the government.
The issue of stigma and discrimination as well as care and treatment for HIV positive people is often overlooked in a low prevalence country like Bangladesh.
The late Director of Global Programme on AIDS Jonathan Mann pointed about three phases to the AIDS epidemic in any society: l The first is the epidemic of HIV infection (entering the community silently and unnoticed).
l Second is the epidemic of AIDS, which appears when HIV triggers life threatening infection.
l Thirdly is the epidemic of stigma, discrimination, blame and collective denial, which makes it so difficult to effectively tackle the first two.
We can learn from other countries about these phases and act accordingly. UNGASS summit also put emphasis on these issues as they expressed “Stigma, silence, discrimination and denial, as well as lack of confidentiality, undermine prevention, care and treatment efforts and increase the impact of the epidemic on individuals, families, communities and nation.” At the same time “full realisation of human rights for all” is seen as an essential element in a global response to HIV/AIDS.
We have to look at the HIV/AIDS issue as a matter of urgency, issue of everybody. HIV/AIDS is not only a health issue -- it is the issue of every sector. Strong commitment and active participation at all levels of the society is essential for an effective response to the epidemic. Let us put our hands together to fight against HIV/AIDS. Our task is still doable. We should not allow any spark to light a fire. But for that -- there is no scope for complacency. Time bomb is ticking -- even for us.
Dr AZM Zahidur Rahman is Advocacy Adviser, UNAIDS.