World AIDS Day 2005
"Stop AIDS: Keep the Promise"
1st December, 2005

Acquired Immunodeficiency Syndrome (AIDS) is a deadly disease. AIDS was first reported in the United States in 1981 and has since become a major worldwide epidemic. Human Immunodeficiency Virus (HIV) causes AIDS. By killing or impairing cells of the immune system (i.e., body's defense mechanism), HIV progressively destroys the body's ability to fight infections and certain cancers. Individuals diagnosed with AIDS are susceptible to life-threatening diseases called opportunistic infections, which are caused by microbes that usually do not cause serious illness in healthy people. AIDS usually develops between 2 and 10 years after infection with HIV. A person with AIDS eventually dies from diseases (Tuberculosis, Pneumonia, Lymphoma, Kaposi's sarcoma, Cervical cancer and other types of cancer, Toxoplasmosis etc.) caused by the infections associated with HIV. New treatments have slightly improved the survival rates of people with AIDS, but there is no cure of AIDS, to date. Fortunately, with proper information and precautions, AIDS is preventable. Also, once infected with HIV, early diagnosis and treatment can help AIDS patients live longer.

How Do People Become Infected With HIV?

The HIV virus is present in body fluids, e.g., blood, semen, vaginal fluid, breast milk and other body fluids containing blood. When any of these body fluids from an infected individual enters into another uninfected individual she/he may get infected with HIV. Followings are the main ways people acquires HIV infection:

* Having unsafe sex (without properly using a latex condom throughout the sexual intercourse) with someone who has HIV.

* Unsafe (without Blood screening or HIV testing) blood transfusion (Transfusion of HIV infected/contaminated blood).

* Using needles for intravenous drug use that are contaminated with HIV.

* Body piercing or tattooing or being cut with needles, razors, or other sharp objects that are contaminated with HIV and have not been properly sterilized.

* In addition, children can be infected in the womb, during childbirth, or during breast feeding if their mothers are HIV infected.

World Statistics:

AIDS is a deadly disease and it has been spreading worldwide alarmingly. It is considered the most devastating pandemic in human history. About 4 crore (40 million) people around the world are currently living with HIV. About 2.5 crore (25 million) people died from AIDS so far including about 30 lakhs (3 million) in last year alone. Everyday 15000 new infections take place. If the devastating disease continues to explode at the present rate, it is estimated that, by 2010 in Africa alone more than 4 crore (40 million) children will become orphan due to AIDS. Although it is often erroneously considered a disease of the developed nations the disease is actually spreading in developing countries several orders of magnitude faster. It has been estimated that almost 95% of the world's AIDS patients belong to developing countries. Nearly 700,000 adults have become infected in South East Asia in the year 2000. East Asia and the pacific is mostly still keeping HIV at bay, with some 130,000 new infections in the current year. Overall, as of end of 2000, the two regions combined are estimated to have 64 lakhs (6.4 million) people suffering from HIV/AIDS.

HIV/AIDS: Situation in Bangladesh:

In the coming years AIDS is going to be a serious problem in Bangladesh, if we fail to undertake appropriate prevention measures immediately. Given the inadequate biomedical resources, prevention is the only choice for a country like Bangladesh. Unfortunately, like many of the HIV affected countries prior to their experiencing the epidemic, both the Government and the public in Bangladesh bears a wrong perception that AIDS may not be a big problem for a Muslim conservative country like Bangladesh. However, such a perception may be devastating. If we look at the African and Islamic countries like Indonesia, we can easily foresee the future picture for Bangladesh if we fail to preempt and learn lessons from these tragedies in other countries and act immediately and decisively.

Clearly, the people and the Government of Bangladesh need help tackling the menace of HIV and its consequences. Despite being away from the country, as an expert and as a responsible citizen I find it my obligation to offer my expertise in helping my motherland. Over the past few months, I devoted myself in developing a comprehensive yet practical and feasible plan to help Bangladesh Government in tackling this alarming tragedy. The attached document elaborates my plan.

Out of 40 million global HIV cases, more than 6 million people are living in South East Asia. In the neighboring country India alone, about 4 million people are already infected with HIV/AIDS. Bangladesh, being one of the world's highly populated countries, is highly susceptible to the transmission of epidemic. Recent sentinel surveillance by the Bangladesh Government reveals that the high-risk groups such as injecting drug users, commercial sex-workers, and truck drivers have 2% prevalence of HIV. Manipur of India and Myanmar surround Bangladesh with high prevalence (50%) of HIV, which indicates

that Bangladesh is passing 'window of opportunity', and without HIV prevention program this country will have epidemic of HIV/AIDS, which would be disastrous for this poor country. The whole situation would be out of control. A comprehensive HIV/STDS prevention program including mass awareness coupled with targeted behavioral intervention for high-risk groups, community based education program, and capacity building are some of the steps urgently needed for tackling the HIV problem in Bangladesh.

Bangladesh is the eighth most populous country in the world with a population of about 154 million. Rapid urbanization and industrialization have increased the scope of mobility within the country and job opportunity outside the country as well. During the past two decades, the urban population has grown from 6 million in 1974 to 21 million in 1994, and it is expected to grow to over 50 million by 2014. About two million migrant workers live in Middle East and South East Asian countries.

In the context of HIV/AIDS, Bangladesh is considered as a "Low Prevalence but High Risk" country. The social and cultural environment is not favorable for the people, who have already been identified as infected or affected from HIV/AIDS. There are many Bangladeshi people, who believe that as our people strictly observe cultural values HIV infection would not spread. Denial of reality, stigma, fear, discrimination and violence of human rights increase the invisibility of the HIV/AIDS in the society. The invisibility of a large number of HIV infected people has further complicated the situation. It is still unknown how many people are living with HIV/AIDS in Bangladesh. On the other hand, studies conducted in 1989-1997 suggest that we have a high prevalence of STIs. One investigation said, "the estimated number of STIs in the country was 2.3 million", which clearly indicates that diseases that spread through unprotected sex are extremely prevalent. So, we however must not adopt a complacent attitude in this respect as our country has all the determinants for an explosive outbreak of HIV/AIDS epidemic. Curses of poverty, illiteracy, ignorance, increased number of migrant workers, unsafe practice in health service, unsafe sex practice, proximity of Bangladesh to the so-called 'Golden Triangle' & high prevalence of STDs, make Bangladesh alarmingly vulnerable.

Drug use increases the HIV risk. The danger, of becoming infected with HIV by sharing injecting equipment is well known, and real. Unemployment, slum housing, family fragility, physical and sexual abuses that give rise to a risk environment of violence for many young people in the region. In addition, increased number of migrant workers, unsafe practice in health service, unsafe sex practice etc. further increases the susceptibility. The experts are perturbed at the presence of male sex workers in Dhaka. They assert that the dreadful killer disease AIDS will spread easily due to the manner in which these workers are being used in perverted sexuality. Most of these male sex workers and adolescents are youths. There is great danger of spread of AIDS virus through these male sex workers. The reason is that the HIV virus gets an easy way of infection due to the problem of injury so commonly associated with anal sex.

Regarding transmission, the last national surveillance report reveals that the mode of transmission is more through heterosexual contact. Although, 2.5% of intravenous drug users were found HIV positive and rate of infection in CSW is 0.3 to 0.6%.

Number of HIV/AIDS patients in Bangladesh

About the status of HIV infection, we are still uncertain about the exact number of infected persons, government reports only 208 infected persons whereas SEA/WHO regional office estimated that 13,000 adults are living with HIV/AIDS in Bangladesh till April 2001.

HIV Diagnosis:

One should keep in mind HIV infected individuals are afraid to come out and get a test and there are a very few facilities for a test in Bangladesh. There are only 7 government diagnostic centers for confirmatory ELISA test for detection of HIV antibody in blood. These are BSMMU, Army Hospital, IECDR, IDH at Dhaka and others are at Chittagong, Sylhet and Khulna Medical College Hospitals. In private level there are certain laboratories that are also performing the test. At NGO level CAAP is the only organization that provides free HIV testing (Rapid test only) since 1997. Recently ICDDR`B has started confirmatory testing however; it is very expensive [see below].

HIV Treatment Care and Prevention:

Absolutely speaking there are no treatments for HIV in Bangladesh. The anti-retroviral drugs are not available here. Certain tests, which are a free requisite for the treatment i.e., CD-4-cell count, viral load detection etc. are not available. Recently ICDDR`B tried to start CD-4 cell test but had to stop it because of non-availability of reagent. They charge Tk. 2,500.00 to 3,500.00 for every test, which is beyond the reach of HIV infected persons.

Some NGOs are trying to provide treatment for opportunistic infections and maintenance of nutrition and counsel and train them on hygiene and healthy living.

But this type of treatment is also very expensive, costing about Tk 6 lakhs (US $10,000) per patient per year. So, prevention is still the only practical means for tackling the problem. We have to act immediately and urgently to prevent AIDS epidemic out break in Bangladesh.

Awareness About HIV/AIDS:

Unlike other plagues, the spread of HIV/AIDS depends upon human behavior. Educating people must therefore be considered the first priority and the government should come forward to make people well aware of what it is, how it spreads, and how it can be controlled. If people do not know, they cannot be persuaded to take preventive measures. It is therefore clear that creating mass awareness about HIV/AIDS is of great importance and necessity. A workshop recently observed with concern that the number of HIV and AIDS patients has been rising in the country through transfusion of infected blood. Further, poverty, a lack of education and human rights abuses of women and children, which are here in plenty contribute to the spread of the deadly disease. So people must have the basic knowledge about HIV

There are many NGOs working in the field of HIV/AIDS but activities are limited to awareness creation and BCC. GOB already has a favorable policy in combating HIV/AIDS. It has integrated HIV/AIDS with the primary health care component under DG health and there is separate Line Director, Program Manager etc. for implementation of the program. But the services are also limited to awareness creation and prevention. The 47 blood transfusion centers operated by the GOB throughout Bangladesh are given instruction to screen the blood before it is transfused. Unfortunately most of the times these centers can not provide the service because of lack of resources. Many people do not know this and they have no concern.

While I discussed the situation of AIDS in Bangladesh and their causes and remedies above below are a list of key points to summarize the above discussions.

Why HIV is increasing in Bangladesh?

Factors for a rapid outbreak of HIV/AIDS exist in the country:

Insufficient awareness and knowledge about HIV/AIDS (Lack of basic knowledge about HIV/AIDS)

* Lack of sex education and social awareness,

* High prevalence of STIs,

* Wide unsafe practice in blood transfusion (blood screening is not mandatory, growing number of private clinics, unsafe injections) unscreened blood exchange,

* Vulnerable geographic location: Common border with neighboring countries with high 50% prevalence of HIV,

* Unsafe sex or unprotected sex: Low levels of condom use in general and more importantly by sex workers.

* High levels of needle sharing among injection drug users. Intravenous drug use,

* Massive internal and external migration/mobility of people,

* Underestimation by high-risk individuals of their own risks for HIV.

* High population density and rapid urbanization,,

* Well developed Commercial sex industry,

* Poor health facilities: inadequate health facilities for treating widespread STI are very much common,

* Extreme poverty

* Low status of women,

* high percentage of young people

* Sexual exploitation and violence

* Premarital and extramarital sex in Bangladesh is common and widespread presently (study report)

* All types of male travelers separated from their wives occasionally engaged in commercial sex (study report).

* A majority of married men reported unprotected sex with a sex worker, street girl, and another man (study report)

* High numbers of clients among some sex workers (study report).

In addition to these:. polygamy, male to male sex,

Because of these factors a vast number of populations in Bangladesh remain exposed to HIV infection.

Present problems of AIDS in Bangladesh

? Exact size and rate of current infection and illness is unknown: Bangladesh has not yet been able to get a clear picture of the epidemic. Enormous gap exists between the estimates of Government and UNAIDS, WHO.

? Lack of knowledge about the epidemic: Few people are aware of the HIV epidemic in Bangladesh. Many people are not aware of what risky behavior is, how those attribute to catching or transmitting the infection or how to avoid it.

? Lack of concern: Although GoB has made some commendable progress in terms of setting motion in the prevention work of HIV/AIDS, still there seems to have a level of complacence about the disease among the all segments of the people including politicians, policy makers and general population.

? Bangladesh people in general profess good cultural and religious values that generally restrain them from sex outside wedlock. But Indonesia has not been protected by its cultural and religious value. Moreover, many study reports that premarital and extramarital sex in Bangladesh is common and widespread. Caldwell et al (1997) found that nearly half of their respondent had engaged in sex before marriage in Bangladesh.

The same study found that a significant proportion of all types of male travelers separated from their wives occasionally engaged in commercial sex. Third Sentinel Surveillance shows that a majority of married men reported unprotected sex with a sex worker, street girl, and another man in the past month.

Almost all of these men had sex with their wives in the same month resulting a total of two thirds to be exposed to the risk of STIs, HIV and Hepatitis through their husband's behavior even though none of them had any risk behavior (source: HIV in Bangladesh: where is it going, Background document for the dissemination of the third round of national HIV and behavioral surveillance, Nov, 2001).

Risky behavior is very common in some groups of people:

The global experience shows that in the beginning of the epidemic, HIV infection is initiated in any country with high risk group like CSWs, IDUs, or MSMs. It then reaches its peak among them and eventually shifts to the bridge population followed by general population.

The factors that facilitate the epidemic to take place in a society, all of them (described earlier) are in play in Bangladesh. Besides these some of the cultural and behavioral factors also make the country extremely vulnerable to HIV/AIDS epidemic i.e. Intravenous drug use, unscreened blood exchange, polygamy, extra and premarital sex, unprotected sex, male to male sex, inadequate health facilities for treating widespread STI are very much common.

E-mail: abunasar.hoque@yale.edu

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