STATE OF THE EPIDEMIC

Bangladesh, with a population of 136 million, had about 13,000 adults and children living with HIV infection at the end 2002, according to UNAIDS estimates. However, only 248 HIV cases have actually been reported. Significant underreporting of cases occurs because of the country's limited voluntary testing and counseling capacity and the social stigma, which leads to the fear of being identified and detected as HIV positive.
The HIV-prevalence rate among adults between the ages of 15 and 49 is still relatively low, at 0.1 percent of the population. As expected, rates are higher in specific groups, such as injecting drug users who have left treatment (1.7 percent) and commercial sex workers (0.5 percent), according to a national behavioral and serological surveillance undertaken in 2001.

RISK AND VULNERABILITY

Although overall HIV prevalence is low, behavior patterns and extensive risk factors that facilitate the rapid spread of the infection are prevalent, making Bangladesh highly vulnerable to an HIV/AIDS epidemic. These risk factors include:

A large commercial sex industry with roughly 36,000 workers, each seeing an average of 18.8 clients per week for brothel-based sex workers, and 44 clients per week for hotel-based workers.

Consistent condom use is low: The majority of brothel-based sex workers report at least some sex without condoms with their clients. Among the clients, such as rickshaw pullers and truckers, about 83 percent have never used condoms when buying sex.

Significant prevalence of sexually transmitted diseases (STDs) among sex workers in Central Bangladesh. About 43 percent of female sex workers and 18.2 percent of male sex workers have syphilis. This and other STDs facilitate the spread of HIV infection and serve as indicators for low condom use and other high risk sexual behaviors.

Injecting Drug Users (IDUs): In Central Bangladesh, among 93.4 percent of over 500 injecting drug users, needle sharing is routine. These drug injectors are not an isolated population—they are often married and sometimes sell sex to customers and their own blood to hospitals and clinics.

Lack of knowledge: While knowledge of HIV is nearly universal among sex workers and their clients, it is extremely low among the general population. In 1996-97, only 19 percent of women who have been married and 33 percent of men had ever heard of AIDS. In 2001, many still could not identify the basic routes of HIV transmission.
NATIONAL RESPONSE TO HIV/AIDS

Government. In late 1996, the Directorate of Health Services in the Ministry of Health and Family Welfare (MOHFW) issued a National Policy on HIV/AIDS. A high-level National AIDS Committee (NAC) was formed, with a Technical Advisory Committee, and an STD/AIDS Program Unit in the ministry. The NAC includes representatives from key ministries and NGOs and a few parliamentarians. Action has been taken to develop a multisectoral response to HIV/AIDS. Strategic action plans for the National STD/AIDS 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, recently Bangladesh has strengthened programs to improve its response.

Nongovernmental Organizations (NGOs). Around 200 NGOs working with STD/AIDS have formed a network, and about 50 are actively engaged in HIV/AIDS-related activities, 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 IDUs. Building their capacity 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, including a social marketing program; peer education and condom promotion activities; information, education, and communication efforts; STD treatment; surveillance and operational research; and the provision of capacity building to NGOs.

ISSUES AND CHALLENGES: PRIORITY AREAS

Preventing a widespread epidemic will only be possible if vigorous action is pursued, including:

• Scaling up the behavioral change activities and health promotion interventions for high-risk behaviors and vulnerable groups.
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  Expanding advocacy and awareness efforts for the population at large, seeking to attain a higher level of public awareness on HIV transmission and prevention.
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  Promoting the social acceptability of condom use and ensure adequate supply and access.
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  Reducing discrimination of those infected with HIV, or groups engaging in high-risk behaviors, through implementation of appropriate advocacy, policies, and related measures.
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  Strengthening Government of Bangladesh capacity for program planning, implementation, monitoring, and evaluation.
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  Promoting NGO capacity for program planning, implementation, monitoring, and evaluation.

Strengthening mechanisms for collaboration and coordination within and between government, the nongovernment sector, development partner agencies, and other stakeholders.