The Himalayan Kingdom of Bhutan, though isolated geographically, is not impervious to HIV. Increasing cross‐border migration and international travel, combined with behavioral risk factors, mean Bhutan could face increases in HIV infections. With HIV prevalence currently very low, there is still time to stop its spread.
State of the Epidemic
To date, with more than 14,000 people tested in a population of less than 700,000, only around 200 cases of HIV have been detected in Bhutan. People tested include general population (mostly ANC attendees), armed forces, prison inmates, truckers/taxi drivers and STI and TB patients, and some sex workers, tested through various means, including blood donation, contact tracing, surveillance, voluntary testing and medical referrals. This places prevalence at well below 0.01 percent. UNAIDS estimates that about less than 1000 people could have been living with HIV/ AIDS at the end of 2009, most of whom are unaware they are infected. Given efforts made to identify existing cases, it is unlikely significant pockets of cases will be identified in the near future. Moreover, the number of annual cases identified has leveled off, with the peak in 2007.
People living with HIV in Bhutan come from diverse occupational backgrounds and districts. They include farmers, housewives (half identified through contact tracing), armed forces, and female sex workers. Mode of transmission is primarily sexual. There are about an equal number of men and women identified as HIV positive. Two‐thirds are between 20 and 49 years of age.
Despite Bhutan’s low HIV prevalence, data collected during the last 3 years indicate that there are some population subgroups engaged in unprotected risk behavior that are not being reached by the program. In contrast to other countries, where HIV is spread primarily through sex work, injecting drug use (IDU), and men having sex with men (MSM), data indicate that while Bhutan does have some IDU and some MSM, the numbers do not appear to be significant. However, in a close-knit society it may be particularly difficult for these groups to come forward. While commercial sex work exists, it is primarily informal sex work and casual sexual networking concentrated in some specific subgroups that could be an important vehicle for transmission of HIV if not addressed appropriately. Among the more important risk factors are:
Prevalence of Sexually Transmitted Infections (STIs): STIs facilitate the spread of HIV infection. Although the exact magnitude of STIs in Bhutan is not known, gonorrhea, the most common, has an estimated annual incidence of about 2 percent among the adult population. Syphilis, for which all blood donors and pregnant women are screened, shows a slightly lower rate. Data from a Behavioral Surveillance Survey with Most at Risk Populations found the proportions having had an STI symptom in the last year is very high amongst bar girls (between 30‐40%) and quite high amongst truckers and RBP in Samdrup‐Jonkhar, and taxi drivers in Thimphu. With respect to data on STI symptoms, the recent General Population Survey (GPS 2006) found about 5‐6 percent of men and 8 percent of women had had a STI symptom. STI symptoms are highest amongst urban men. Knowledge about STI symptoms was low, particularly among women, and few, if any, knew that STIs could be asymptomatic in women. The same survey found only 73 percent of those surveyed knew condoms could prevent STIs. The STI data are consistent with low HIV prevalence.
Spread of Commercial and Informal Sex Work: While the border town of Phuentsholing, with its thriving commercial sex, remains a transmission zone, sex work is perceived to be spreading to other border towns, and some interior districts of Thimphu, Paro, Trongsa, and Mongar. There is also informal sex work, particularly in the interior districts, which is more difficult to identify. Furthermore, frequent police raids in the border area towns force sex work underground making it more difficult to reach sex workers with prevention services.
Risk of Substance Abuse: Substance abuse is associated with a higher risk of HIV infection as it can lower inhibitions and increase sexual risk‐taking behavior. Studies on substance abuse in Bhutan indicate that although injecting drug use seems minimal, alcohol consumption in the country is extensive, and there are indications of the growing use of marijuana, amphetamines, and other drugs among young people.
Less Rigid Sexual Norms: Sexual norms for both men and women are perceived to be less stringent in Bhutan than in other South Asian countries. The GPS of 2006 noted multiple concurrent relationships are not uncommon. One‐fifth of all married people have engaged in extramarital sex in the last year, and 14 percent of unmarried people had sex in the last year. Rates are considerably higher among urban males (43 percent had extramarital sex in the last year, and 42 percent of urban single men had premarital sex in the last year). Although their partners are generally girlfriends and acquaintances, 15 ppercent of men having sex with non‐regular partner frequent sex workers. While overall this is a small number (4‐5 percent of all married men), casual attitudes towards sex by this small sexually active subgroup of the population and their links to risk groups could eventually lead to small, truncated epidemics. On the other hand, the Bhutanese Government’s open discussion of sexual health issues, unlike in other countries of the region, makes it easier to address this factor.
Gender and Rural/Urban Disparities: Awareness about HIV is about 99 percent. Knowledge about how HIV is transmitted and how it can be prevented is less universal, although highest on knowledge about the preventive effects of condom use. Knowledge is higher in urban areas than rural areas, and higher among men than women. Condom use is also higher in urban areas, and higher among men. Condom use with extramarital sex partners is high (76 percent in urban areas, 64 percent rural areas, 84 percent for urban males but only 44 percent for urban females). Condom use in premarital sex is also high, at 73 percent in both rural and urban areas. Women’s limited ability to negotiate condom use and their more limited knowledge puts them at greater risk.
Invisibility of Most‐at‐Risk Populations in Bhutan: In most countries, HIV has spread from most‐at‐risk populations (MARPs), including sex workers, injecting drug users and men who have sex with men. While HIV is not concentrated amongst these groups in Bhutan, a Behavioral Surveillance Survey and a sexual networking study have identified subgroups engaged in risky behavior. Reaching them has proven difficult as the limited privacy that results from the closeness of social networks leads many to hide “unacceptable” behaviors more than in larger and more fluid societies.
National Response to HIV and AIDS
Government: The Royal Government of Bhutan acted early to initiate HIV prevention activities in the country. In 1988, five years before the first HIV infection was detected in the country, the Royal Government established a National HIV/AIDS and STD Control Program (NACP). The program is managed by the Ministry of Health.
Bhutan has demonstrated a strong political commitment to preventing and controlling the spread of HIV. Her Majesty Queen Ashi Sangay Choden Wangchuck is the UNFPA Goodwill Ambassador and an outspoken advocate of reproductive health, including HIV prevention. Furthermore, the government’s Ninth and Tenth Five‐Year Plans have identified HIV/AIDS and STI prevention and control as one of the most important programs for addressing emerging health issues and promoting better health for women and adolescents in Bhutan.
The national program, which has been financed substantially by donors, has focused on advocacy and awareness raising, behavior change communication and condom promotion and distribution, enhancing the information base on the epidemic, screening blood to ensure blood safety, integrating management of STIs into primary health care, improving treatment of STIs, setting up voluntary counseling and testing at the National Referral Hospital and two independent facilities in Thimphu and Phuentsholing, providing AIDS treatment and supporting the forming of networks of PLWA to improve adherence, access and care. It has also worked closely with line ministries and district governments to address HIV and AIDS.
The program needs to focus on areas that are most effective in a low‐prevalence setting: providing prevention services to and empowering those who are most at risk of contracting HIV (MARPs); reducing stigma and discrimination; and making greater use of available data on the epidemic in defining program direction, and decision making, and improved field supervision to ensure better outcomes.
Non‐Governmental Organizations (NGOs): Although local NGOs are nonexistent, Bhutan has civil society organizations such as religious bodies and youth groups which have an important role to play in HIV prevention and care.
Issues and Challenges: Priority Areas
The usual approaches to reach MARPs are difficult to mount in Bhutan: In a low prevalence setting, a concentrated epidemic will only be averted if MARPs are adequately reached. In most countries these interventions are implemented by NGOs and Community Based Organizations (CBOs). However, there are practically no NGOs in Bhutan and CBOs lack the necessary experience and none have worked on HIV. Even bringing PLWA to work together is difficult given the lack of privacy and stigma. NACP needs to encourage and train CBOs to work with MARPs and gradually scale up interventions. A well designed communications program can assist in reducing stigma. Given the less rigid attitudes towards sex, NACP also needs to target “hot spots” to increase condom use.
Human and physical constraints: Bhutan has a serious shortage of manpower at all levels and available staff is overstretched. Skills in some areas are lacking and the necessary technical expertise is often not available in‐country. The rugged terrain and distances that need to be traveled to reach much of the country imply higher costs and greater difficulties to provide the necessary supervision and support. Better coordination and more targeted use of resources can improve program performance given limited human resources. This implies a strengthening of the information base on risk behavior and epidemic trends, as well as data to monitor the response. District level capacity needs to be strengthened.
World Bank Response
In June 2002, the World Bank, in collaboration with the Royal Government of Bhutan, carried out a rapid situational assessment, as a basis for discussions on possible support for the Government’s efforts to combat HIV and AIDS. In June 2004, the Bank approved an IDA grant of US$5.8 million for the HIV/AIDS and STI Prevention Project. The project sought to scale up the Government’s efforts to contain the epidemic and reduce the incidence and prevalence of STIs. Specifically, it sought to:
· Expand HIV and STI prevention interventions, especially for most‐at‐risk populations.
· Initiate care and treatment for people living with HIV and AIDS (PLWHA).
· Improve STI prevention and treatment.
· Improve human resources through long‐term and short‐term training and country exchanges, particularly in the area of public health and laboratory science.
· Improve blood safety.
· Improve management and technical capacity of Dzongkhags, line ministries, and civil society organizations to undertake HIV/AIDS prevention.
· Strengthen surveillance, monitoring and evaluation, and information systems for better decision making on policies and programs, and expand the information base.
· Engage community‐based organizations, NGOs, local governments, and multi‐sectoral agencies at the district level in expanding and accelerating HIV/AIDS interventions among populations.
The project closed in 2011. Its achievements and implementation were moderately unsatisfactory.
At this time, the World Bank provides analytical support to the country through its regional HIV/AIDS program.