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"Linkages of Sexual and Reproductive Health in Prevention of HIV in Bangladesh"
Welcome address by Mr. Arthur Erken
UNFPA Representative
In his remarks on the importance of linkage, he mentioned that UNFPA is working with the government and other partner organizations in prevention of HIV in Bangladesh, and also on the issues of linkages of HIV and sexual and reproductive health. The existing partnership and collaboration would widen the scope of this linkages for required coverage and quality of care. He was confident that the roundtable discussion would contribute to reach this goal. He said that there are close associations between sexual and repro-ductive health and HIV/AIDS, as significant portion of HIV infections are sexually transmitted or related to pregnancy, childbirth and breastfeeding. Linkages for HIV prevention provides a good opportunity to accelerate country level response to the epidemic. In his oen words, " The major challenge to this linkages process is to know how to maintain network, coordinate and harmonize multi-stakeholder response that aim at successful implementation. In terms of HIV prevention, we are making praiseworthy progress through national response for effective prevention of HIV. People at all strata of society ate now far more open to talk about HIV/AIDS and inclined to contribute to HIV prevention within their own capacity. In terms of comprehensive HIV prevention, we need a concerted effon through active participation of all government and non government organizations, public and private institutes, and people at all level of society. ”
Mr Earken believes that the effon of the roundtable discussion on linkages of HIV will be instrumental in building a national consensus for a concerted effort and consolidate the existing partnership and contribute in the long run to prevention of HIV in Bangladesh.
Dr. Shamsul Haque Gazi In order to understand the definite linkage between sexual and reproductive health in prevention of HIV/ AIDS. There is definite linkage among these three. There are certain issues here.
1) The vulnerable groups of HIV/AIDS, sexually transmitted diseases and the reproductive health.
2)HIV/AIDS and STI transmitted from one person to another in the same way
3) There is relationship between HIV/AIDS and reproductive health. For instance, the transmission between the mother and her child. If the mother is infected with HIV then her child becomes infected with HIV too.
The background story behind why the person become infected with HIV and STI, such as poverty, gender, inequality etc
Another cause for linkage is that clients of HIV or STD are like to have their services from one centre and it will minimize the stigma and discrimination.
Presentation of Keynote paper by Dr. Khandaker Ezazul Haque.
Dr Ezaz, HIV Officer,UNFPA gave the main presentation on the subject.
He started by giving a conceptual aspect regarding linkage for HIV prevention in Bangladesh. In his words, “We are embarking on this issue to get proper direction for cost effective, higher coverage and quality of services for HIV prevention effon. I will give you some examples of why linkage of HIV is important in the context of Bangladesh. I will
also give some references of international as well as national documents on SRI I and HIV linkage. In fact linkages is the understanding of synergies, at the conceptual and strategic levels, that can be created when seeing common approaches to addressing specific health issues. Here, we are considering HIV and Sexual and Reproductive Health(SRH) as health issues.
"There are some key stakeholders in Bangladesh who are providing services to injecting drug users. My question is, are we addressing the sexual and reproductive health issues for this high risk groups? If not, are we considering the aftermath for not addressing the sexual and reproductive health issues for this high risk group like injecting drug users. I can cite an example here; some female injecting drug users sell sex as a source of earning money to buy drugs for injecting. In this respect, the female injecting drug users need adequate information and commodities for safe sex in addition to other support services. So, for HIV prevention among these injecting drug users, we need to link sexual and reproductive health services through promotion of condom use among them. I am giving this example to emphasize on pragmatic and comprehensive aspect to develop and adopt strategic direction, and decisions for a very comprehensive intervention to widen coverage of services both for HIV prevention and sexual and reproductive health services. Please note that the majority of the buyers at sex-selling settings are married and there is potential risk of spousal transmission of HIV In this respect 1 am trying to reiterate the gravity of the problem and importance of sexual and reproductive health service for both the spouses for HIV prevention, and also for prevention of vertical transmission of HIV from parent to child. Besides the brothels in Bangladesh, there are numerous hotels in Dhaka city, and research studies indicate that a significant number of hotels are involved in the sex business. Moreover, research findings also suggest that there is evidence of residence based sex work in Dhaka city. In this respect, I would like to mention that there is a increasing demand for paid sex in Bangladesh, and the number of clients is increasing day by day. Since most of the clients are married, they may transmit HIV and other sexually transmitted infections from sex workers to their spouses.
In terms of linkage, we should ask ourselves; are we adequately addressing the sexual and reproductive report health issue so that the client as well as their spouses are oriented, sensitized for negotiation of safe sex with their spouses and or sex partners. We should remember that this also an issues of reproductive right. This issue, I expect, will trigger further questions and discussion during this roundtable event. During discussion we need to discuss on how to devise strategies to considers and determine the underlying factors that can lead to the linkage. In terms of linkage of HIV with sexual and reproductive health, it is crucial to clarify ourselves that whether we are instrumental enough at our own implementation stage for these linkages. In this regard, we also need to know whether we are in a process of partnership and collaboration or not, as these issues are must for linkages. We need to consider these partnership and collaboration issues as strategic direction that can increase coverage and qual-itv of services, and we
believe that without partnership, networking or collaboration, it is impossible to have a linkage of sexual and reproductive health with HIV We need to analyze our activities to ensure that the interventions are instrumental to link this SRH with HIV. In this regard, during discussion, we can also consider and reflect our points of view in terms of partnership, networking, coordination, cooperation, etc. so that we can have better understanding and contribution for linkages. Without being judgemental, we are mostly implementing both the sexual/reproductive health activities and HIV in a vertical manner, and there is a deficiency in the horizontal, linkage. Question is what might be the aftermath if there is only vertical approach. There are some studies that indicate that we have very low coverage of services. But, there are good examples of scope of linkage in Bangladesh. We know that we have very good infrastructure and man power for health and family planning services, and field workers are providing these services. In this respect, I would like to mention that there is ample scope of linkages of sexual and reproductive health with HIV in terms of dual protection through use of condom. In a single setting of field activity, the service provider can provide a message related to HIV/sexual transmitted and also family planning, when service provider is discussing about condoms. But these things are not actually happening at implementation level. This leads to a low coverage for information dissemination in relation to HIV transmission which leads to unsafe sexual practice and thus contributes to higher rates of HIV transmission. Moreover, low coverage for HIV related information contributing to poor demand and less uptake for Voluntary Counselling and Testing(VCT). It is crucial to emphasize on this issue considering the linkages issues. We believe that the VCT is an issues of risk perception to create demand for HIV testing on voluntary basis. If demand is not created, voluntary HIV testing service will remain underutilized, and consequently number of persons carrying HIV will be undiagnosed and underestimated. So, linkages of HIV with sexual and reproductive health services can pave the way for higher coverage of information and services for increasing risk perception and demand for VCT services. Considering the HIV context in Bangladesh, lack of linkage is creating an underutilization of VCT service in Bangladesh. As a result, there is possibility of low estimation of HIV positive cases in Bangladesh and consequently data might be misguiding.
In the context of linkages, male participation is an important factor for linkages of HIV with sexual and reproductive health. Due to cultural factors, Bangladesh is a patriarchal society, in most of the cases, access to sexual and reproductive health services depends on male counterpart. Therefore it is also important to consider male participation, gender equity and equality through social and economic empowerment of women. The proposed linking process can enhance the scope of addressing these social issues with HIV as gender, empowerment, SRH and HIV are interrelated.
The strategies for linkages of SRH and HIV should be Instrumental enough to provide the required services as per the demand. It should be as simple as possible, and we don't want to take this sexual health issue as rocket science, we need to make it simple and doable if we really want to make it happen in reality. 1 can cite another example in relation to this simplicity; when the family planning and maternal health service providers provide services at their respective field, they can discuss basic HIV issues in a nutshell.
In relation to linkages issues, engagement of the key policy and decision makers is very important, and without their active and meaningful engagement, linkages will remain a conceptual and theoretical issue as it is related to strategic direction, budgeting and monitoring. In addition to conceptual clarification, we also require perpetuated commitment, technical expertise for implementation.
In order to make this linked approach sustainable, we also need sustainable funding both for SRH and HIV intervention. Also, high turnover of service providers is a big problem especially in the government level as it weakens this approach when there is frequent transfer of trained staff.
Referral for voluntary counselling and testing during the antenatal checkup is a big issue, and based on my own experience, it is controversial for some planners and service providers. I got feedback from them who are involved in the antenatal check-up, and they do not agree to have the provision of VCT service at antenatal set-up as they think it might create apprehension among others who visit for antenatal check up. This conception makes the linkages a very complex issue to implement for more coverage and quality of services.
But, maternal health issue in terms of antenatal check-up can be a good scope of linkages. During antenatal check up, service provider can assess the risk of HIV infection based on personal history and counsel for voluntary testing accordingly.
Linking HIV with SRH also important to increase accessibility and availability of services for People Living with HIV(PLHIV). Usually they remain hidden in the society due to associated stigma and discrimination. The proposed linkages issues can increase their physical, cultural and economical accessibility for their sexual and reproductive heath. In this regard, we need new strategic direction and robust implementation plan to address this at national level.
Directorate General of Health Services has taken praiseworthy leadership for developing Prevention of Parent to Child Transmis-sion(PPTCT) guidelines, and we hope that this new
guideline will pave the way for future linkages of HfV with other maternal and child health issues.
1 would like to request National AIDS/STD Program to adopt pragmatic plan to incorporate linkages issues in the next National Strategic Plan on HIV to fill gaps in terms of strategic direction in this national document. Finally, we at UNFPA are providing support both at national and divisional level through training, workshops, roundtable discussion and forming partnership forum etc. In addition, and we have also provided training for the HIV focal point of the different ministries on HIV and linkages issues.
Dr Farhana Haque
We have a very good governmental infrastructure, one of the best in Southeast Asia, which could be used for providing HIV services as well. But I have two queries:
Tsince Bangladesh is a low prevalence country regarding HIV, how feasible would this be to promote VCT. Do we have enough resources or VCT centers and would people panic if we instructed them to go to those centers? would that be feasible?
2ndFor allowing VCT services for antenatal checkup, firstly, what proportion of women in Bangladesh go for such checkup? Secondly, in antenatal checkup, we already have this provision that we should go for certain infectious disease screening. Is it a need to provide VCT services or should we make that screening compulsory for everyone?
Saleh Ahmed
Bondhu Social Welfare Society works on transgender issues (locally we call hijra population). There are evidences that HIV program for them are still very limited in Bangladesh. 4% of the total spending of the HIV program in the country's regions. That is the degree of limitation. And if you come back in Bangladesh the current coverage for this particular population is less than even 17%, 1 am talking about data from one year back when we were part of implementing the HNPSP program in Bangladesh. We do not know the current scenario and the reason why I am particularly talking about that small proportion of population is because if we think about HIV itself we need to look at other respect as well. Particularly regarding the linkage and sexual and reproductive health 1 would like to say that reducing HIV vulnerability is not only due to lack of knowledge or condom distribution, but also about changing the environment, risky behavior and it is critically imnortant to address the
social factors, laws and policies that discriminate against trangender. The female drug users are another area. 1 would like to particularly emphasize on issues related to sexual and reproductive health because it is important to focus on coordination between the ministries because according to the ministry of health and family welfare we have to promote condom for HIV prevention or even the reproductive health. However, ministry of home affairs says it is a crime and therefore illegal. So I think it is important to focus on that coordination. The second area we need to focus on is the coordination and better understanding between the NGOs and the donors.
Arthur Erken
The real victims of the epidemic will probably be married women who ultimately will be in the receiving end of the sexual behavior of ID users. Ultimately the male sexual behavior is at the driving end and the married women are at the receiving end. How do we encapsulate them in way that can protect them with the attitude of not seeing them as sexual beings but seeing them as human beings in totality? The government is indeed in the ministerial coordination. There are of course mixed messages coming out. On one end the public health, and strategy of condom promotion at the same time. If a woman is picked up in the street with a condom in her pocket then she is criminalized so there are mix messages. The government should address this matter with a holistic approach.
Ashita Sultana
The youth are the most vulnerable people.
There is a generation gap within ourselves. Knowing about HIV and keeping it to myself is not a smart thing. I have to share it with others, especially those who are vulnerable, like who take drugs and so on. I believe media can play active role in creating awareness and changing people's mindset. In the advertisement for condom or contraceptives on television they don't say use condom to be safe from HIV. The young generation is not exposed to enough information on the subject. So media can take the responsibility ofdisseminat-ing information. Education ministry will also have to take more responsibility. Otherwise we may get misinformation from friends or some unreliable sources.
Kalpana Rani
I think linkage, Integration and reaching to people the services is the real challenge in Bangladesh. Here we have good infrastructure setup but if you talk about quality of health services then it is really poor. Whatever facilities are available at union level, women and .young girls are not having any access to them. Health workers who are going door to door can really help in preventing many health problems by .providing resources for preventing HIV. It is seen that sex workers have good level of awareness regarding use of condoms for prevention of HIV/AIDS. In the people who are going to them also have awareness about condoms preventing HIV/AIDS. But 90% of the clients are not motivated to use condoms. We are talking about awareness, services and information but where is the behaviour change part? So they are not taking the information about unsafe sex seriously. Education is very important if you want to prevent HIV/AIDS. Though Bangladesh is a low prevalence country but all the other patterns for increase in infection are here. So we have to talk about those other patterns to prevent HIV infection. When we are talking about linkages we have to think about at what point or level. Are we talking about linkages among government agencies or collaboration among NGOs even within the communities? We also have to look at it form donors' perspectives. Since the 90s lot of money has come to Bangladesh for die HIV/AIDS sector but big percentage is being used politically. It is not reaching the poor who need the support.
Bridget Johnson:
There is the whole issue of what do we link and how do we link and what are the benefits of this linkage. One thing dial we are missing out is that we are not doing is that we are not doing much at the level of planning. We need to start looking at HIV and reproductive health, generally in a different perspective. We know that STI and HIV are sisters and brothers because diey are transmitted the same way. 1 think there is a huge opportunity we are missing and we have a lot of venues to see that if this could be a precursor or a pointer, to the fact there are some risks but what arc we doing about that. We also need to know about the multiplicity’ of risk, because we talk about most at risk population and we divide them into ID users and sex workers. But we forget that an ID user could also be a sex worker. We have collaboration, linkages, but 1 don't see packaging. How we package what we are delivering now, because we have a sex worker who now has
access to condoms and other things but doesn't have the access to needle syringe exchange. I say we need to go back to information about the trend and pattern of HIV in this country. What is it telling us or pointing us, to who else apart from the core group we are looking at, that we actually need to start looking at. If. we identify what services are required and how can we reach these people. When we are potentially able to reach them, then we know what we need to package and link together. 1 don’t believe we have done a careful analysis, hence it is so difficult, every body has this good intentions but when it comes to reality, it fizzles out because we haven't done the ground work yet and I think we need to start from there.
Dr.Mozammel Haque Health, especially sexual and reproductive health, is a right of the people. The important thing is to develop more linkages between the government and NGO sectors for services concerning HIV and sexual and reproductive health and family planning. There should be mainstreaming HIV with sexual and reproductive health sector. Similarly, mainstreaming sexual and reproductive health with the HIV sector. We also have to develop program linkage between these two sectors. Our policy document mentions so many important things, such as linkages, programative linkages, comprehensive programs in relation to sexual and reproductive health and so on. Unfortunately, we have not been able to spell out very clearly that our study document, or strategic document( National plan) is a nice document but the document has some lacking in terms of reflecting these issues in a clear and distinct manner. This is why we need to support national AIDS program to revise the national strategic plan. So, we should start thinking from now on that these specific issues need to be very’ clearly spelled out in the national strategic document so that the NGOs and other government organisations that are working among the most risk population and also the general population would be able to provide services in relation to sexual, reproductive health and HIV If it is clearly reflected and addressed in the national document then it would help them to design their future programs and projects which will help develop the real linkage of sexual and reproductive health and HIV/AIDS through government and non government setup. from PAGE 12 Mohuya Leya Mainstreaming means mainstreaming within the organisation...who are working in that organisation. People who are working with sex workers or in the field of HIV/A1DS for twenty years or so are not showing interest in going for their own checkup or in VCT. This is the mindset. This is one big challenge.
Kazi Ali Reza
In schools or colleges or universities much attention is not given to the areas of sexual and reproductive health and HFV/AIDS. Students are not much aware of these issues. A lot of attention has to be given on sexual health in order to prevent HIV infection. We mostly talk about high risk and low risk population but it has to be seen from a broader perspective....like what is the situation in the educational institutes. Some senior teachers of schools in Bogra told me that they never touch the chapter on HIV/A1DS in the school curriculum. They do not have the language as to how to teach those topics. So, we need to develop some sort of mechanism to produce a communicative language to teach this topic, which is normally treated as taboos. Lack of information is another issue that has to be addressed. Media can come to our help in this regard. Awareness is the only remedy:
Arun thia Zaidi Urmi According to reports most of the HIV positive are returnee workers. We cannot do surveillance on them or under-take prevention programmes. But if they infect their wives and if the wives come for antenatal care we shall be able to identify them if we offer them VCT. Since we do not have enough resources for VCT we have to think in that line. We should be able to routinely offer VCT to all pregnantwomen.
Mukti
Under the care and support programme little work is done for reproductive health issue. We should know about how to strengthen this area and how to establish linkage. We should also work with the IDU families. We need to give more emphasis on working with women who are infected with or affected by HIV infection.
Tan vir Hasan
According to a BRAC university ongoing study many HIV positive are facing discrimination from health care providers like doctors, nurses, technicians etc. Service providers need proper training.
Dr Farhana Haque
If we really need to integrate and establish linkage we need to do more research. How do we train people and what would be the best ways to train people, how do we talk amongst ourselves to find the effective way, these need to be addressed first.
Bridget Johnson
I think we need to look at the fact that most infected people are returnee migrants. There have also been mentions of private health care sector joining as partners. I think we should carry them along. And we should have a mechanism for assessing risks, which we don't have at the moment. If we do not have such a mechanism what will happen is we shall check a multitude of people but come up with only a few cases. That would not be cost affective. We need to be strategic. We must know where to start.
Shuvashish Roy
Young people are mostly ignorant about the things being discussed here. So, can this kind of seminar be organised in all the educational institutes in the country? Voluntary organisations like NYF and NYSB will disseminate the findings.
Dr. Samir Kumar
linkage between sexual and reproductive health and HIV is already there but we could not provide the services in a coordinated manner. The referral system has never been established in this country. At GTZ we tried to establish linkage at provider level. But it was not possible because of lot of negative attitudes. Sometimes service providers are afraid of losing clients. So they do not want to refer to other service providers. Sexual and reproductive health and HIV cannot be separated. The service should come together. From IOM we have seen that migrant workers who are tested positive are deported by the authorities. But in most cases when they come back they hide the fact. Then they transmit the disease to their wives. So, when they plan to have a child they need advice to know about the risk of transmission of HIV to their child. In such cases during antenatal checkup VCT must be offered.
AfsanaTaher
I think a very important aspect is the softer issues which is the behaviour change and I think having this sort of roundtables with the media is the right strategy for getting the media involved. Media can play an important part where they can disseminate the information. When we are talking about providing services to the target groups, we are talking about people who are already infected by HIV or who are living with AIDS. Isn't it better to stop it from happening? Rather than going to target groups, which means that these people are already infected why can' t we do something so that we don't have to go to them? But even with information people will get affected, but the number will be less. Labourers coming back with infection said they would not have done anything wrong if they had known about HIV infection. So it's human behaviour that we are talking about here. If people have the information they will take action to protect them.
Dr. Ezazul Haque
We are discussing for many years the issue of linkages but from my own observation we are still at the discussion stage. My appeal to NSP of DJGS is to start piloting the linkages of mains treaming issues so we can know whether we can go ahead withit.
Dr. Salil Panakadan
Stigma is still a big problem for AIDS response across the world, just not in Bangladesh. People who come to the clinics health providers would feel stigmatized: why AIDS people are coming in here? The discourse has changed from the early 90's to now that linkages have more or less happened. But what about integration? Now integration is the big challenge in terms of services. How do we integrate in Bangladesh? Do we add HIV services to existing family planning or reproductive health services? That is one way of doing it. The other is existing service points for HIV, do we add services of family planning and reproductive health? So both ways can be done. But there may be instances where you cannot really link as things stand today. Because how many family planning workers are meeting people in clinics where high risk people would feel comfortable in accessing services? That is the question, so in some circumstances you may want to keep some services slightly separate in order to promote access.
As for integration, we can start with NASP - the next step is national strategy plan. Linkages and integration, that are something we can get done. Then there are ongoing programmes where we can make a difference. Straight away we can conclude areas like providing integrated services. Both in the HIV field which is what the RCC will support financially and technically. So these are action points which may come out of our discussion, issues that can be addressed straight away. Of course the debate and the advocacy goes on in terms of reduction of stigma and including HIV services in all reproductive and sexual health services.
Arthur Erken
If we look back at the discussion that we had, there are couple of things that we have all agreed upon. One is, there is a whole set of missed opportunities. Everyone agrees that Bangladesh has a good infrastructure to be used where linkage can actually take place. It's not happening but it should happen there. Some mentioned FWAs and FHAs who are out there in the villages everyday but missing opportunities to address this issue. And the FWA who goes out to most families doesn't say anything about sexuality and HIV It’s a missed opportunity that we can fix right now. It's not much to do about that, so these missed opportunities are the first issues we should be addressing. I think the second point we mentioned about the short quick wins is indeed the fact that the government is working on the national strategic plan. I think we all agreed that that plan should be comprehensive and should look at HIV in a holistic manner. Not necessarily only at a targeted interventions scope. We are not only looking at high risk population but looking also at population at large and what their needs are. For that to happen and for that to be good, we need much more information about epidemic. We are still working on an epidemic that we don't fully understand. We don't fully understand the sexual behaviour of us. We have to know what the patterns are so that our interventions can be targeted towards that.
The issue of research was mentioned otherwise our national strategic plan will also again deal with a lot of missed opportunities. I think a very important point was mentioned, not often done in this kind of dialogues, is of course the issue of youth sexuality. Unless we start opening up the debate on youth sexuality and the
role of the formal education system, we are missing out on a lot of the things on youth sexuality. We can close our eyes and put our heads in the sand pretending that nothing happens with the young people and that they are not having relationships, including physical relationships with each other. We are of course risking ourselves and risking the next generation. We also agree that there are two things that are probably non-threatening to the society. One is the education system, if we first of all make the curriculum better, and secondly train the teachers better, we can at least alleviate some of the burden from our parents.
The media is nonthreatening way of providing young people and people in general with good information on how to protect yourself, where to go if you have a problem and so on. Then I want to mention again the issue of STIs. STI is a huge problem in this country. It means it's a result of unsafe sex. And yet we are not linking it with HIV and not with family planning. We are again missing out on a large public health problem. We are only addressing in isolation but we are pot opening up to a larger issue of why you are having unsafe and unprotected sex, how do you protect yourself against pregnancy and so forth. Then comes the issue ofVCT. And here again the media can play a large role. There are certainly opportunities already existing but of course needs to be promoted further. We should broaden the antenatal services we provide. Yes, only half the pregnant women at the moment do that but at least its half the population of pregnant women. It's not enough but at least it's a good group to start with. So why don't we do that? I think and here's again where government and the media can play a role is that VCT should not be seen as a threatening thing but as a prevention thing. It's now being seen as a stigmatizing thing as AIDS detection. People are going there to check whether or not they have HIV, and of course people are scared and the natural tendency is not to do it. As for VCT, it has to do with how you advocate, how you market it, how you promote it as a way of series of prevention methods.
For long term wins, there are two things: one is the issue of male sexual behaviour. It's the ultimate driver. It's the men who predominantly ID use, are going to female sex workers and having sex with men. I don't want to stigmatize men but men are the drivers. I think the issue of responsible male sexual behaviour is something we should take up seriously. The young people experimenting with sex, which is totally normal, but there is no programme around it. There are no good role models around it that promote responsibility in your relationship and ultimately in your family life. And again the role of media is extremely important in creating that environment of responsibility. This society is changing very rapidly and I think we do not totally understand the pace of that. 1 think the intergenerational gap is a threat to our programmes. We need to be able to talk their language and in a non-moralizing way. The best messages that we can give them is actually positive enforcement. In other words the positive rewarding of certain behaviour. It's more important than saying no to sex. I'm not promoting it but if you go for it, please have it safe.
Now who does the linkage? I think it should be NASP and I think from my side and certainly from the development point of view we obviously would like to see NASP take that role. We would like to see NASP strengthened to be able to play that role. So we look forward to this strategic document from the government as to how it sees the linkages between sexual and reproductive health and HIV andAIDS.
MahfuzAnam
We would like to assure you that we are very committed to this issue. If media has any role to play, we in The Daily Star pledge to play it. We perhaps don't know how to... so that's where your guidance we seek, you'll tell us how to do, tell us what to do and then we will transform it in the media language ourselves and do it. I recently have had an opportunity to go to Malawi in Africa. I was there as an election monitor, and there I picked up a book on the impact of AIDS on Africa. It is really horrendous, I think almost one third of the population of Africa has died. And there are countries where farmlands are barren, there's no human being to cultivate. Africa was the first continent to bear the bnint of it, we learn from their experience. 1 think we have been comparatively lucky. However I think one of the basic flaws that we suffer from is a sense that we are lucky. We really don't know how deep the problem is simply because we have not looked at it. There is cultural hesitations, religious hesitations and so on. HIV deals with very intimate aspects of human behaviour and the whole culture has evolved on the basis of privacy. It is unique, it is very special. And therefore it is not in the public domain as such. Unfortunately this disease has brought it into the public domain. However, the dis-ease itself has forced us to go in for public awareness to basically prevent our security. It's self preservation, it is a choice between being alive and dying. And that's precisely what happened to Africa. Challenge for us and the UN organization and all of you and specially the
media is how to bring up this message within this cultural context, within the sensitivities, but yet being-effective. And that is J think is the challenge with which we are all grappling. Because ultimately survival is what your basic instinct is.
We would like to be your
partner in this effort. Because 1 think this is very vital for Bangladesh's future and vital for our citizens. So we are, if you like, already convert to the issue, you don't need to convince us any more. All you need to do is show us the way to move forward.
***Recommendations
I.Have Io attain the objectives through active participation of all government and non government organizations, public and private institutes, and people at all levels of society.
2 .Female injecting drug users need adequate information and commodities for safe sex in addition to other support services.
3 .For HIV prevention among injecting drug users, we need to link sexual and reproductive health services through promotion of condom use among them.
4 .Sexual and reproductive health services for both the spouses for HIV prevention, and also for prevention of vertical transmission of HI V from parent to child has to be given due importance.
5 .For better understanding and contribution towards linkages, greater emphasis has to be given on partnership, networking, coordination and cooperation.
6 During a single field visit, service providers can provide a message related to HIV/STI and also family planning and use of condoms.
7 .lf demand is not created, voluntary HIV testing service will remain underutilized, and consequently number of persons carrying HIV will remain undiagnosed So, demand has to be created.
8 .Linkages of HIV with sexual and reproductive health services can pave the way for higher coverage of information, increasing risk perception and demand for VCT services.
9 .Male participation is an important factor for linkages of HIV with sexual and reproductive health.
1O.l n relation to linkages issues, engagement of the key policy and decision makers is very important
11 .Need sustainable funding both for SRH and HIV intervention.
12 . Maternal health issue in terms of antenatal check-up can be a good scope of linkages.
13 Linking HIV with SRH also important to increase accessibility and availability of services for People Living withHIV(PLHIV).
15) We need new strategic direction and robust implementation plan.
16) National AIDS/STD Program should adopt pragmatic plan to incorporate linkages issues in the next National Strategic Plan on HIV.
17) Governmental infrastructure should be used for providing HIV services as well.
18) It is critically important to address the social factors, laws and policies that discriminate against trangender.
19) Media can play active role in creating awareness and changing people's mindset.
20) Education ministry will have to take more responsibility
21) We need to know about the multiplicity of risk.
23) We need information about the trend and pattern of HIV in this country.
24) STI is a huge problem in this country and that should be taken as the first priority.
25) There should be mainstreaming HIV with sexual and reproductive health sector. Similarly, mainstreaming sexual and reproductive health with the HIV sector.
26) We have to develop program linkage between these two sectors
27) Media should also do some advocacy with the policy makers and the civil society.
28) . Students are not much aware of these issues. Besides high risk and low risk population it has to be seen from a broader perspective, including educational institutes.
29) We need to develop a mechanism to produce a communicative language to teach this topic.
30) Encompassing the entire young generation is needed for greater result.
31) We should be able to routinely offer VCT to all pregnant women.
32) We should work with the IDU families. We need to give more emphasis on working with women who are infected with or affected by HIV infection.
33) Service providers need proper training.
34) Young people are sexually active but it is a hidden subject. There should be more discussion on these issues.
35) To integrate and establish linkage we need to do more research.
36) We should have a mechanism for assessing risks.
37) When couples plan to have a child they need advice to know about the risk of transmission of HIV to their child. In such cases during antenatal checkup VCT must be offered.
38) Attention has to be given towards behaviour change aspects.
39) NSP is to start piloting the linkages of mainstreaming issues.
40) Advocacy should go on in terms of reduction of stigma about HIV/AIDS.
41) The national strategic plan should be comprehensive and should look at HIV in a holistic manner.
42) We should broaden the antenatal services.
43) The concept of responsible male sexual behaviour needs to be promoted.
44) We would like to see NASP strengthened to be able to play that role.***
List of Participants
MahfuzAnam, Editor, The Daily Star Mr. Arthur Erken, UNFPA Representative Afsana laher, Operations Manager, UNFPA Bridget Job-Johnson, UNICEF Dr. Said Panakadan UNAIDS Dr. Shanisul Haque Gazi, DPM, NASP Dr. Md. Mozammet Haque, UNODC Dr. Khandaker Ezazul Haque, UNFPA Kazi Ali Reza. Officer in Charge, UNIC Md.Tanvir Hasan, BRAC University Ashita Sultana Chowdhury,National Youth Forum Shuvashish Roy, NationalYouth Forum Md. Shafiul Islam, UNFPA
Dr. Farhana Haque, Independent University, Bangladesh Mohuya Leya .Manusher Jonno Foundation Kalpana Rani, CARE, Bangladesh
Arunthia Zaidi Urmi, ICDDR.B
M.S. Mukti, MuktoAkash
Saleh Ahmed, Bondhu Social Welfare Society Dr. Samir Kumar Hawladar,IOM Achintya Das Gupta, UNFPA consultant