HIV in Bangladesh has continued to remain at relatively low levels in the most at risk population groups. The main reason for this low prevalence could be the early and sustained HIV prevention programs targeting high risk groups backed by a state-of-the-art surveillance system. Another contributing protective factor could be the high rates of male circumcision. There is, however, a concentrated HIV epidemic among injecting drug users (IDU), primarily due to sharing of unclean syringes and needles. As a result, the rate of new infections is still on the rise and Bangladesh is the only country in the South Asia Region where new infections are rising.
State of the Epidemic
Bangladesh’s latest round of serological surveillance (2011) showed that HIV prevalence among all key populations remained below 1 percent with the exception IDU. Although the overall prevalence of HIV was 1.2% among IDU in 2007/08, there is a concentrated epidemic among male IDU in Dhaka. The prevalence of HIV in this cluster increased from 4% in 2002 to 7% in 2007/08, which fell slightly in 2010 to 5.3%.
In Bangladesh, as in other countries in the region, HIV risk arises mainly from unprotected paid sex, sharing of used needles and syringes by IDU, and unprotected sex between men who have sex with men. Recent data suggest that there are two key areas for HIV in the country:
· IDU: HIV prevalence has started to increase amongst IDU in Dhaka, rising to 7% in 2007/08 in one neighborhood. This epidemic “hot spot” is clearly a priority.
· International returned migrant workers: This group accounts for the majority of passively reported cases of HIV in the country and may be a potential source of HIV transmission.
An epidemic may also be emerging among female sex workers (FSW) in towns bordering India. The numbers are small but this area needs careful attention. Genetic analysis found that the HIV strains were different in each of these groups as of 2005. There is some overlap amongst sex workers, as some inject drugs and some engage with migrant workers. A rising epidemic in one of these groups, therefore, could lead to a spread in others.
The following factors associated with IDU, increases the risk of transmission of HIV infection:
· Sharing of needles and syringes: Although declining trends are observed, the rates of sharing are still high – the rate of borrowing needles decreased from 65% in 2002 to 55% in 2006/07 and the rate of lending fell from 90% to 60% over the same period. A four-year cohort study on male IDU in Dhaka revealed that the incidence of hepatitis C virus is declining (22% in 1999/00 to 12% in 2007), which suggests adoption of safer injecting practices or rising immunity of the cohort. However, the rates of sharing needles and syringes are still high, putting IDU at risk, especially when injecting drugs and unprotected sex intersect.
· Low condom use among IDU and intersection with other high risk practices: buying sex from sex workers and having female sex partners without using condoms are common among male IDU. In 2006/07 in Dhaka, 66% of the male IDU bought sex from FSW and 41% used condom during last sex with an FSW. Only 26% of IDU reported consistent use of condoms.
· Lack of knowledge and awareness: People aged 15 to 49, account for approximately one-fifth of the total population of Bangladesh. Although the estimated HIV prevalence in this age group is negligible, a national survey in 2008 found that they lack knowledge and awareness about HIV and that many are engaged in risky sexual practices while having limited access to reproductive health information and services. A majority of the people surveyed (90%) had heard about HIV/AIDS but their level of knowledge of the disease was low. Only 38% of the people surveyed could correctly identify two or more routes of HIV transmission and only 40% could identify two or more routes of prevention. A national survey of youth found that almost 20% of unmarried males had premarital sex and one in three of them had their last sex with a sex worker. Around 10% married males reported having sex outside of marriage, half of whom had their last sex with a sex worker.
· Other socioeconomic factors: The knowledge about HIV transmission in Bangladesh (2004) showed significant difference related to wealth, gender, education, and rural versus urban location. The lowest awareness was found among uneducated women in rural Bangladesh (20%) compared to educated urban males (78%). Homeless IDU have been shown to be more than five times as likely to be HIV positive as IDU living at a fixed address. Besides, IDU from HIV epidemic neighbourhood in Dhaka (in comparison with IDU living in the rest of Dhaka) were less educated, fewer were currently married, and had lower average income.
National Response to HIV/AIDS
Government: In late 1996, the Directorate General 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, non-government organizations and a few parliamentarians. Action has been taken to develop a multi‐sector response to HIV/AIDS. Strategic action plans for NASP set forth fundamental principles, with specific guidelines on a range of HIV issues including testing, treatment, safe blood supply, prevention among youth, women, migrant workers, sex workers, and STIs. While earlier commitment was limited and implementation of HIV control activities was slow, Bangladesh has strengthened its programs to improve its response. The Government of Bangladesh prepared the National Strategic Plan for HIV/AIDS for the period 2004‐2010 under the guidance of NAC and with the involvement and support of different stakeholders. As a follow-up to this, the Government recently completed the National HIV Strategic Plan for 2011 to 2015. Efforts to mainstream HIV/AIDS in public sectors outside the Ministry of Health and Family Welfare were initiated through designation and training of focal points on HIV/AIDS in 16 government ministries.
Non‐Governmental Organizations (NGOs): More than 380 NGOs and AIDS Service Organizations have been implementing programs/projects in different parts of the country. These initiatives focused on prevention of sexual transmission among high‐risk groups involving mostly female sex workers, MSM, IDUs, rickshaw pullers and truckers. NGOs are often better positioned than the public sector to reach vulnerable populations, such as 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 vulnerable populations and prevent the spread of HIV.
Donors: The Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) is active in Bangladesh supporting targeted interventions for key populations. Bangladesh has received funds from Rounds 6 and 8 and RCC (Rolling Continuation Channel) of GFATM.
Issues and Challenges: Priority Areas
Vigorous action is required to prevent further spread of HIV in Bangladesh. Key tasks include:
· Provision of comprehensive care, support & treatment for people living with HIV through public health facilities.
· Scale up behavior change activities and health promotion interventions for key populations, particularly IDU, men who have sex with men, sex workers and migrant workers.
· Expand advocacy and awareness among the general population through multi‐sectoral agencies. Incorporate results of serological and behavioural surveillance surveys in the IEC campaign.
· Promote the social acceptability of condom use and ensure adequate supply and access.
· Reduce stigma and discrimination against people living with HIV and key populations at higher risk of HIV exposure through appropriate advocacy, policies, and related measures.
· Strengthen the Government’s capacity for program implementation, management, and monitoring of program activities.
· Strengthen NGO capacity for program planning, implementation, and supervision of interventions.
· Strengthen mechanisms for collaboration and coordination within and between government, the non‐governmental sector, development partners, and other stakeholders to avoid duplication of services and increase the effectiveness of the national response.
World Bank Response
The World Bank supports the Government's two‐pronged strategy: first, increasing advocacy, prevention, and treatment within the Government's existing health programs, and second, scaling up interventions among key populations.
The HIV/AIDS Prevention Project (HAPP 2000‐2007) jointly financed by the Bank and DfID provided US$27 million of assistance to support the scaling up of interventions among groups at high risk in a rapid and focused manner while strengthening overall program management. Three UN agencies assisted the Government in the implementation of key project components: UNICEF managed the NGO service delivery component, WHO managed the blood safety activities, and UNFPA managed the capacity building component. With the closure of the project, HIV interventions have been integrated into the Government of Bangladesh and Multi‐Donor supported Health, Nutrition and Population Sector Program (2005–2011). With the closure of HNPSP, HIV interventions are now being implemented as part of the Government and Multi-Donor support Health Sector Program – Health, Population and Nutrition Sector Development Program (HPNSDP), 2011 to 2015. For HIV interventions, US$25 million of resources have been allocated from HPNSDP for targeted interventions for most-at-risk groups, treatment, advocacy and training.